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Docketing Statement (Changes) DSCB 15-134B - Pennsylvania
| Docketing Statement (Changes) Form. This is a Pennsylvania form and can be used in Docketing Statements Department Of State . |
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Docketing Statement (Changes) BUREAU USE ONLY : DSCB:15-134B Revenue Labor & Industry Other _____________________ File Code_________ Filed Date ____________ Part I. Complete for each filing: Cu rrent name of entity or registran(sut rvivor or new entity if merger or consolidation ): Entity number, if known: Incorporation/qualification date i n PA: State of Inc: l FeEIN: dera Specified effective date, if ay: n Part II. Check proper box: Amendment (complete Section A) M erge r, Consolidation or Division (complete Section B,C or D) C onsolidation (complete Section C) Di vision (complete Section D) C onversion (complete Section A & E) C or rection (complete Section A) Te rmination (complete Section H) R evi val (complete Section G) Dissolution before Commencement of Business (complete Section F) Section A Check box(es) which pertain to changes: Na me: Re gistered Office: Number & street/RD numb& er box number City State Zip County Pu rpose: St ock (aggregate number of share authorized): Ef fective date: . Term of Existence: Ot her: . Section B Merger Complete Section A if any changes to surviving entity: Merging Entities are: (attach sheet for additional merging entities ) DSCB:15-134B-2 Name: En tity # , if kno wn: DSCB:15-134B-2 Effective date: Inc./qual. date in PA. State of Inc. Name: En tity # , if kno wn: Effective date: Inc./qual. date in PA. State of Inc. <<<<<<<<<********>>>>>>>>>>>>> 2 Section C - Consolidation Consolidating Entities are: (attach sheet for additional consolidating entities) Name: Entity #, if known: Inc./qual. date in PA. of In c. State Name: Entity #, if known: Inc./qual. date in PA. of In c. State Section D Division Forming new entity(s) named below: (attached sheet for additional entities) Name: En tity Number: Name: En tity Number: Check one : Entity named in Part I survives. n(ay changes, complete Section A) En tity named in Part I does not survive. Section E Conversion (complete Section A) Check one : Converted from nonprofit to profit Conv erted from profit to nonprofit Section F Dissolved by Shareholders or Incorporators Before Commencement of Business Section G Statement of Revival (complete Section A for any changes to revived entity) Entity named in Part I hereby revives its charter or articles which were forfeited by Proclamation or expired. Section H Statement of Termination (attach sheet for additional entities involved) filed in t he Department of State on is/are h ereby terminated. (type of filing made) month/date/year hour, if any If merger, consolidation or division, list all entities involved, other than that listed in Part I: Name: Entity number: Name: Entity number:
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