Statement Of Conversion Limited Cooperative Association Page 4
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54. The purposes for which the limited cooperative association is formed are:
_______________________________________________________________________________________
5. The true names and addresses of the persons organizing the limited cooperative association are:
True Name
(if an individual)
____________________ ______________ ______________ _____
(Last)
(First)
(Middle)
(Suffix)
or
(if an entity)
______________________________________________________
Street address
______________________________________________________
(Street number and name)
______________________________________________________
__________________________ _____ ___________________
(City)
(State)
(ZIP Code)
__________________________ ______________.
(Province – if applicable)
(Country)
Mailing address
______________________________________________________
(leave blank if same as above)
(Street number and name or Post Office Box information)
______________________________________________________
__________________________ _____ ___________________
(City)
(State)
(ZIP/Postal Code)
__________________________ ______________.
(Province – if applicable)
(Country)
The limited cooperative association has one or more additional persons forming the limited
cooperative association and the name and mailing address of each such person are stated in an
attachment.
6.
This document contains additional information as provided by law.
7. (Optional) Delayed effective date:
______________________
(mm/dd/yyyy)
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 the document is the
individual's act and deed, or that the individual in good faith believes the document is the act and deed of the
person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity
with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic
statutes, and that the individual in good faith believes the facts stated in the document are true and the
document complies with the requirements of that Part, the constituent documents, and the organic statutes.
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 named in the document as one who has caused it to be delivered.
ARTORG_LCA
Page 2 of 3
Rev. 4/02/2012
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