Statement Of Conversion Converting A Domestic Entity Into A Foreign Entity Page 2
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1
2
3__________________________ ____ ____________________
(City)
(State)
(ZIP/Postal Code)
_______________________ ______________.
(Province – if applicable)
(Country)
3. The converting entity has been converted into the resulting entity pursuant to section 7-90-201.7, C.R.S.
4.
(Mark the applicable box and complete the statement. Caution: Mark only one box.)
The resulting foreign entity does not maintain a registered agent in this state and service of process
may be addressed to the entity and mailed to the principal address pursuant to section 7-90-704 (2),
C.R.S.
OR
The resulting foreign entity maintains a registered agent to accept service pursuant to section 7-90-
204.5, C.R.S. The person appointed as registered agent has consented to being so appointed. Such
registered agent’s name and address are
Name
(if an individual)
____________________ ______________ ______________ _____
(Last)
(First)
(Middle)
(Suffix)
OR
(if an entity)
______________________________________________________
(Caution: Do not provide both an individual and an entity name.)
Street address
______________________________________________________
(Street number and name)
______________________________________________________
__________________________
CO
____________________
(City)
(State)
(ZIP Code)
Mailing address
______________________________________________________
(leave blank, if same as street address)
(Street number and name or Post Office Box information)
______________________________________________________
__________________________
CO
____________________
(City)
(State)
(ZIP Code)
5.
(If applicable, adopt the following statement by marking the box and include an attachment.)
This document contains additional information as provided by law.
6.
(Caution: Leave blank if the document does not have a delayed effective date. Stating a delayed effective date has significant
legal consequences. Read instructions before entering a date.)
(If the following statement applies, adopt the statement by entering a date and, if applicable, time using the required format.)
The delayed effective date and, if applicable, time of this document are ___________________________.
(mm/dd/yyyy hour:minute am/pm)
Notice:
Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or
acknowledgment of each individual causing such delivery, under penalties of perjury, that such document is
such individual's act and deed, or that such individual in good faith believes such document is the act and deed
of the person on whose behalf such individual is causing such document to be delivered for filing, taken in
conformity with the requirements of part 3 of article 90 of title 7, C.R.S. and, if applicable, the constituent
documents and the organic statutes, and that such individual in good faith believes the facts stated in such
document are true and such document complies with the requirements of that Part, the constituent documents,
and the organic statutes.
CONV_FOR_1
Page 2 of 3
Rev. 2/26/2008
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