Document processing fee If document is filed on paper $150.00 If document is filed electronically Currently Not Available Fees & forms/cover sheets are subject to change. To file electronically, access instructions for this form/cover sheet and other information or print copies of filed documents, visit www.sos.state.co.us and select Business Center. Paper documents must be typewritten or machine printed. ABOVE SPACE FOR OFFICE USE ONLY Statement of Conversion filed pursuant to §7-90-301, et seq. and §7-90-201 Colorado Revised Statutes (C.R.S.) ID number (if applicable): _____________________ 1. Entity name of the converting entity: ______________________________________________________ (must be exactly as shown on the records of the Secretary of State) 2. Jurisdiction under which the converting entity was formed: ______________________________________________________ 3. Principal office street address of the converting entity: ______________________________________________________ (Street name and number) ______________________________________________________ __________________________ ____ ____________________ (City) (State) (Postal/Zip Code) _______________________ ______________ (Province – if applicable) 4. Principal office mailing address of the converting entity: (if different from above) (Country – if not US) ______________________________________________________ (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ ____________________ (City) (State) _______________________ ______________ (Province – if applicable) 5. Form of the converting entity: (Postal/Zip Code) (Country – if not US) ______________________________________________________ 6. Entity name of the resulting entity: ______________________________________________________ 7. Jurisdiction under which the resulting entity is being formed: ______________________________________________________ 8. Principal office street address of the resulting entity: ______________________________________________________ (Street name and number) ______________________________________________________ CONVERT Page 1 of 3 Rev. 6/15/2005 American LegalNet, Inc. www.USCourtForms.com __________________________ ____ ____________________ (City) (State) _______________________ ______________ (Province – if applicable) 9. Principal office mailing address of the resulting entity: (if different from above) (Postal/Zip Code) (Country – if not US) ______________________________________________________ (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ ____________________ (City) (State) _______________________ ______________ (Province – if applicable) 10. Form of the resulting entity: (Postal/Zip Code) (Country – if not US) ______________________________________________________ 11. Use of Restricted Words (if any of these terms are contained in an entity name, true name of an entity, trade name or trademark stated in this document, mark the applicable box): “bank” or “trust” or any derivative thereof “credit union” “savings and loan” “insurance”, “casualty”, “mutual”, or “surety” 12. The converting entity has been converted into the resulting entity pursuant to this section. 13. If the resulting entity is an entity for which constituent filed documents are to be filed in the records of the secretary of state, the converting entity shall deliver to the secretary of state for filing pursuant to part 3 of this article, the constituent filed document that complies with the requirements of the organic statutes. If a constituent filed document is to be filed, submit the constituent filed document for the resulting entity and include the appropriate constituent together with the statement of conversion. Mark this box filed document that complies with the requirements of the organic statutes. Information contained in the statement of conversion controls over any contrary information contained elsewhere in the filed document. The filing fee of the appropriate constituent filed document is included in the filing fee of the statement of conversion. 14. Additional information may be included pursuant to other organic statutes such as title 12, C.R.S. If and include an attachment stating the additional information. applicable, mark this box 15. (Optional) Delayed effective date: ______________________ (mm/dd/yyyy) Notice: Causing this document to be delivered to the secretary of state for filing shall constitute the affirmation or acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the individual's act and deed, or that the individual in good faith believes the document is the act and deed of the person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic statutes, and that the individual in good faith believes the facts stated in the document are true and the document complies with the requirements of that Part, the constituent documents, and the organic statutes. This perjury notice applies to each individual who causes this document to be delivered to the secretary of state, whether or not such individual is named in the document as one who has caused it to be delivered. 16. Name(s) and address(es) of the individual(s) causing the document CONVERT Page 2 of 3 Rev. 6/15/2005 American LegalNet, Inc. www.USCourtForms.com to be delivered for filing: ____________________ ______________ ______________ _____ (Last) (First) (Middle) (Suffix) ______________________________________________________ (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ ____________________ (City) (State) _______________________ ______________ (Province – if applicable) (Postal/Zip Code) (Country – if not US) (The document need not state the true name and address of more than one individual. However, if you wish to state the name and address of any additional individuals causing the document to be delivered for filing, mark this box name and address of such individuals.) and include an attachment stating the Disclaimer: This form, and any related instructions, are not intended to provide legal, business or tax advice, and are offered as a public service without representation or warranty. While this form 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. Questions should be addressed to the user’s attorney. CONVERT Page 3 of 3 Rev. 6/15/2005 American LegalNet, Inc. www.USCourtForms.com