PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Statement of Termination Domestic Corporation DSCB:15-1902/5902 (rev. 7/2015) *1902* 1902 Nonprofit Corporation (§ 5902) Return document by email to: _________________________________ Read all instructions prior to completing. Fee: $70 Check one: Business Corporation (§ 1902) In compliance with the requirements of the applicable provisions of 15 Pa.C.S. § 1902 or § 5902 (relating to Statement of termination), the undersigned, desiring to terminate an amendment that has not yet become effective, hereby certifies that: 1. The name of the association is: _____________________________________________________________________ 2. The current registered office address as on file with the Department of State. Complete part (a) OR (b) ­ not both: (a) _____________________________________________________________________________________________________ Number and street City State Zip County (b) c/o: __________________________________________________________________________________________________ Name of Commercial Registered Office Provider County 3. A copy of the Articles of Amendment to be terminated is attached and set forth in full in Exhibit A. 4. This Statement of Termination has been signed/executed by the corporation that filed the amendment. 5. The amendment has been terminated in accordance with the provisions thereof set forth therein. IN TESTIMONY WHEREOF, the undersigned corporation has caused this Statement of Termination to be signed by a duly authorized officer thereof this ______________ day of ____________________________, 20________. ______________________________________ Name of Corporation ___________________________________________________ Signature ___________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-1902/5902 - 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 1. Give the exact name of the association. The name on this line must match exactly the association name as provided in the articles of amendment sought to be terminated and in the Department's records at the time the Statement of Termination 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 this Statement of Termination is submitted for filing. This field is required. 3. A copy of the Articles of Amendment to be terminated must be attached to the Statement of Termination. This field is required. 4. This statement is required. 5. This statement is required. Signature and Verification The Statement of Termination must be signed by the corporation that filed the amendment. 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. The nonrefundable filing fee for this form is $70. Checks should be made payable to the Department of State. Checks must contain a commercially pre-printed name and address. This form and all accompanying documents shall be mailed to the address stated above. Applicable Law See 15 Pa.C.S. § 1902 and § 5902 for general information on Statement of Termination. Statutes are available on the Pennsylvania General Assembly website, www.legis.state.pa.us, by following the link for Statutes. Who should file this form? Only domestic business corporations and domestic nonprofit corporations may use this form. Articles of Amendment which have been previously delivered to the Department of State for filing but which have not yet taken effect may be terminated before they takes effect by filing a Statement of Termination. The same can be accomplished by filing a Statement of Abandonment (DSCB:15-141). Only an amendment that has not yet taken effect may be terminated under this section. If the articles of amendment have taken effect, they may be corrected under 15 Pa.C.S. § 138 if the requirements of that section are satisfied. Attachments The following, in addition to the filing fee, shall accompany this form: (1) One copy of a completed form DSCB:15-134B (Docketing Statement - Changes) with respect to each association affected by the terminated amendment. Form Instructions 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. American LegalNet, Inc. www.FormsWorkFlow.com