PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Unincorporated Nonprofit Association Agent for Service of Process Appointment/Amendment/Cancellation DSCB:15-9120 (rev. 7/2015) *9120* 9120 Cancellation of statement 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 Check one: Statement appointing agent Amendment of statement In compliance with the requirements of 15 Pa.C.S. § 9120 (relating to appointment of agent to receive service of process), the undersigned unincorporated nonprofit association and/or agent hereby states that: Complete boxes 1-3 for appointment, amendment and cancellation filings 1. The name of the unincorporated nonprofit association is: 2. The address, if any, in this Commonwealth of the above-named association is: Number and Street City State Zip County 3. The name and address in this Commonwealth of the person authorized to receive service of process for the above-named association is: Name Number and Street City State Zip County American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-9120-2 For amendment of statement appointing agent only 4. The name and address in this Commonwealth of the person authorized to receive service of process for the above-named association is changed to: Name Number and Street City State Zip County For cancellation of statement appointing agent only 5. ___The status of the agent [named in box 3] authorized to receive service of process for the above-named association has been cancelled by the association. IN TESTIMONY WHEREOF, the undersigned have caused this Statement, Amendment or Cancellation of agent for service of process to be executed this day of , . ____________________________________________ Name of Unincorporated Nonprofit Association ____________________________________________ Signature ____________________________________________ Title ________________________________________ Name of Agent ________________________________________ Signature ________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-9120­Instructions Pennsylvania Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Web site: www.dos.pa.gov/corps Instructions for Completion of Form: A. Typewritten is preferred. If handwritten, the form shall be legible and completed in black or blue-black ink in order to permit reproduction. The nonrefundable filing fee for this form is $70 made payable to the Department of State. Checks must contain a commercially pre-printed name and address. Enter the name and mailing address to which any correspondence regarding this filing should be sent. This field must be completed for the Bureau to return the filing. If the filing is to be returned by email, an email address must be provided. An email will be sent to address provided, containing a link and instructions on how a copy of the filed document or correspondence may be downloaded. Any email or mailing addresses provided on this form will become part of the filed document and therefore public record. B. Agents resigning must use Resignation of Agent form (DSCB:15-9120D). B. Under 15 Pa.C.S. § 135(c) (relating to addresses) an actual street or rural route box number must be used as an address, and the Department of State is required to refuse to receive or file any document that sets forth only a post office box address. C. Appointment, amendment and cancellation of agent for service of process must be signed by both (i) a person authorized to manage the affairs of the nonprofit association; and (ii) the person appointed as the agent. D. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkFlow.com