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

Statement Of Conversion Limited Cooperative Association Page 5

8. The true name and mailing address of the individual causing the 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/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).

ARTORG_LCA

Page 3 of 3

Rev. 4/02/2012

Statement Of Conversion Limited Cooperative Association Page 5