Statement Of Conversion Converting A Domestic Entity Into A Foreign Entity (Page 3 of 3) in pdf

Statement Of Conversion Converting A Domestic Entity Into A Foreign Entity Page 3

This perjury notice applies to each individual who causes this document to be delivered to the Secretary of

State, whether or not such individual is identified in this document as one who has caused it to be delivered.

7. The true name and mailing address of the individual causing this document to be delivered for filing are

____________________ ______________ ______________ _____

(Last)

(First)

(Middle)

(Suffix)

______________________________________________________

(Street number and name or Post Office Box information)

______________________________________________________

__________________________

____________________

(City)

(State)

(ZIP/Postal Code)

_______________________ ______________.

(Province – if applicable)

(Country)

(If applicable, adopt the following statement by marking the box and include an attachment.)

This document contains the true name and mailing address of one or more additional individuals

causing the document to be delivered for filing.

Disclaimer:

This form/cover sheet, and any related instructions, are not intended to provide legal, business or tax advice,

and are furnished without representation or warranty. While this form/cover sheet is believed to satisfy

minimum legal requirements as of its revision date, compliance with applicable law, as the same may be

amended from time to time, remains the responsibility of the user of this form/cover sheet. Questions should

be addressed to the user’s legal, business or tax advisor(s).

CONV_FOR_1

Page 3 of 3

Rev. 2/26/2008

Statement Of Conversion Converting A Domestic Entity Into A Foreign Entity Page 3