Statement Of Conversion Limited Cooperative Association (Page 2 of 5) in pdf

Statement Of Conversion Limited Cooperative Association Page 2

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.

6. 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)

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 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).

COMB_CONV_LCA

Page 2 of 2

Rev. 4/02/2012

Statement Of Conversion Limited Cooperative Association Page 2