Statement Of Conversion Limited Cooperative Association
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5Form must be filed electronically.
Paper forms are not accepted.
This copy is a sample and cannot be submitted for filing.
Statement of Conversion
Limited Cooperative Association
Filed pursuant to § 7-90-201.7 (3) of the Colorado Revised Statutes (C.R.S.)
1. For the converting entity, its ID number (if applicable), entity name or true name, form of entity,
jurisdiction under the law of which it is formed, and principal address are
ID number
_________________________
Entity name or true name
______________________________________________________
Form of entity
______________________________________________________
Jurisdiction
______________________________________________________
Street address
______________________________________________________
(Street number and name)
______________________________________________________
__________________________ ____ ____________________
(City)
(State)
(ZIP/Postal Code)
_______________________ ______________
(Province – if applicable)
(Country)
Mailing address
______________________________________________________
(leave blank if same as street address)
(Street number and name or Post Office Box information)
______________________________________________________
__________________________ ____ ____________________
(City)
(State)
(ZIP/Postal Code)
_______________________ ______________.
(Province – if applicable)
(Country)
2. The entity name of the resulting entity is _____________________________________________________.
3. The converting entity has been converted into the resulting entity pursuant to section 7-90-201.7, C.R.S.
4.
This document contains additional information as provided by law.
5. (Optional) Delayed effective date:
___________________________
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.
COMB_CONV_LCA
Page 1 of 2
Rev. 4/02/2012
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