PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Statement of Election of Professional Corporation Status DSCB:15-2905 (rev. 7/2015) *2905* 2905 Return document by email to: _________________________________ Read all instructions prior to completing. Fee: $125 In compliance with the requirements of 15 Pa.C.S. § 2905 (relating to election of professional associations to become professional corporations), the undersigned, constituting all of the associates of a professional association, desiring to elect professional corporation status, hereby states that: 1. The name of the association is: __________________________________________________________ 2. Complete part (a) or (b) ­ not both: (a) The address of this corporation's current registered office in this Commonwealth is: (post office box alone is not acceptable) 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. The initial Articles of Association of the association were filed in the Office of the Prothonotary of County, Pennsylvania. 4. The associates of the professional association have elected to accept the provisions of 15 Pa.C.S. Ch. 29 (relating to professional corporations) for the government and regulation of the affairs of the association. IN TESTIMONY WHEREOF, the undersigned constituting all of the associates of the professional association, have executed this Statement of Election of Professional Corporation Status this day of , . Printed name ___________________________________ ___________________________________ ___________________________________ ___________________________________ Signature ___________________________________ ___________________________________ ___________________________________ ___________________________________ American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-2905 - Instructions 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 $125 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. 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. The following, in addition to the filing fee, shall accompany this form: (1) One copy of a completed form DSCB:134A (Docketing Statement). (2) One copy of a completed form DSCB:15-1311/5311/9305 (Statement of Summary of Record) and form DSCB:15-1915/5915 (Articles of Amendment-Domestic Corporation), restating the Articles to set forth all of the information required to be set forth in restated articles of a professional corporation. See 15 Pa.C.S. § 1311(a)(6). D. For general instructions relating to the incorporation of professional corporations see 19 Pa. Code Ch. 33 (relating to professional corporations). These instructions relate to incorporators, corporate name and stated purposes. For specific information relating to professional corporation names see 19 Pa. Code § 17.9 (relating to professional names). For general instructions relating to the incorporation of business corporations see 19 Pa. Code Ch. 23 (relating to business corporations generally). These instructions relate to such matters as corporate name, stated purposes, term of existence, nonstock status, authorized share structure and related authority of the board of directors, inclusion of names of first directors in the Articles of Incorporation, optional provisions on cumulative voting for election of directors, etc. E. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkFlow.com