Docketing Statement (New Entity)

Docketing Statement DSCB:15-134A (Rev 2001) Departments of State and Revenue BUREAU USE ONLY: Dept. of State Entity # _______________________ One (1) copy required Dept. of Rev. Box # _________________________ Filing Period ____________Date 3 4 5 __________ SIC/NAICS _____________Report Code ________ Check proper box: Pennsylvania Entities Foreign Entities State/Country business stock business non-stock professional nonprofit stock nonprofit non-stock statutory close management cooperative insurance limited liability company restricted professional limited liability company business trust Date______ business nonprofit limited liability company restricted professional limited liability company business trust Other domestication division consolidation 1. Entity Name: 2. Individual name and mailing address responsible for initial tax reports: Name Number and street City State Zip 3. Description of business activity: 4. Specified effective date, if any: month/day/year 5. EIN (Employee Identification Number), if any: hour, if any 6. Fiscal Year End: 7. Fictitious Name (only if foreign corporation is transacting business in PA under a fictitious name): 2002 © American LegalNet, Inc.