PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Return document by email to: _________________________________ Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/. Fee: $70 In compliance with the requirements of 15 Pa.C.S. § 3331 (relating to annual benefit report), the undersigned benefit corporation hereby states that: 1. The name of the corporation is: ____________________________________________________________________________________________________ 2. Complete part (a) or (b) not both: (a) The address of this corporation's current registered office in this Commonwealth is ____________________________________________________________________________________________________ Number and Street City State Zip County (b) The name of this corporation's commercial registered office provider and the county of venue is: c/o:_________________________________________________________________________________________________ Name of Commercial Registered Office Provider County 3. A narrative description of: (i) the ways in which the benefit corporation pursued general public benefit during the year and the extent to which general public benefit was created; ____________________________________________________________________________________________________ (ii) the ways in which the benefit corporation pursued any specific public benefit that the articles state is the purpose of the benefit corporation to create and the extent to which that specific public benefit was created; ____________________________________________________________________________________________________ (iii) any circumstances that have hindered the creation by the benefit corporation of general or specific public benefit; and ____________________________________________________________________________________________________ (iv) the process and rationale for selecting or changing the third-party standard used to prepare the benefit report. ____________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-3331 - 2 4. An assessment of the overall social and environmental performance of the benefit corporation against a thirdparty standard applied consistently with any application of that standard in prior benefit reports or accompanied by an explanation of the reasons for any inconsistent application. 5. The name of the benefit director and the benefit officer, if any, and the address to which correspondence to each of them may be directed. 6. The compensation paid by the benefit corporation during the year to each director in that capacity. 7. The annual compliance statement of the benefit director described in section 3322(c) (relating to benefit director). Check applicable statements and strikeout inapplicable statements. In the opinion of the benefit director, the benefit corporation acted in accordance with its general and any specific public benefit purpose in all material respects during the period covered by this report. In the opinion of the benefit director, the directors and officers complied with sections 3321(a) (relating to standard of conduct for directors) and 3323(a) (relating to standard of conduct for officers), respectively. In the opinion of the benefit director, the benefit corporation or its directors or officers failed so to act. Following is a description of the ways in which the benefit corporation or its directors or officers failed so to act: 8. A statement of any connection between the organization that established the third-party standard, or its directors, officers or any holder of 5% or more of the governance interests in the organization, and the benefit corporation or its directors, officers or any holder of 5% or more of the outstanding shares of the benefit corporation, including any financial or governance relationship which might materially affect the credibility of the use of the third-party standard. IN TESTIMONY WHEREOF, the undersigned registrant has caused this Annual Benefit Report to be signed by a duly authorized officer this _______ day of _________________, 20______. _______________________________________________________ Name of Corporation _______________________________________________________ Signature _______________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-3331 Instructions Pennsylvania Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Website: www.dos.pa.gov/corps 1. Give the exact name of the association. The name on this line must match exactly the association name as shown in Department's records at the time the Annual Benefit Report is submitted for filing. This field is required. 2. Current address. The address provided must be the association's registered office address (a) or Commercial Registered Office Provider (b) as on file with the Department of State at the time the Annual Benefit Report is submitted for filing. This field is required. 3 - 8. See 15 Pa.C.S. § 3331 for more information. Additional pages may be attached as needed. A benefit corporation may change from year to year the standard it uses for assessing its performance. But if a benefit corporation uses the same standard for assessing its performance in more than one year, the standard must either be applied consistently or the benefit corporation must provide an explanation of the reasons for any inconsistent use of the standard. Fields 3-8 are required with the exception that the information in field 6 (relating to compensation paid to directors) and any financial or proprietary information may be omitted from the benefit report as filed with the Department of State. Signature and Verification An authorized representative of the association must sign the Annual Benefit Report. Signing a document delivered to the Department for filing is an affirmation under the penalties provided in 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities) that the facts stated in the document are true in all material respects. This field is required. General Information Typewritten is preferred. If handwritten, the form must be legible and completed in black or blue-black ink in order to permit reproduction.