PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Domestic Business Corporation Statutory Close Corporation (15 Pa.C.S.) Statement of Breach of Qualifying Condition (§ 2309A) Statement of Cure of Breach of Qualifying Condition (§ 2309B) Name Document will be returned to the name and address you enter to the left. Address City State Zip Code Fee: $70 In compliance with the requirements of the applicable provisions (relating to involuntary termination of statutory close corporation status; proceedings to prevent loss of status)/(relating to notice of cure of breach), the undersigned business corporation which is a statutory close corporation hereby states that: 1. The name of the corporation is: 2. The (a) address of this corporation’s current registered office in this Commonwealth or (b) name of its commercial registered office provider and the county of venue is (the Department is hereby authorized to correct the following information to conform to the records of the Department): (a) Number and Street City State Zip County (b) Name of Commercial Registered Office Provider c/o: County 3. Check box relating to applicable provision: Statement of Breach: The provision included in its Articles pursuant to 15 Pa.C.S. § 2304(a) (relating to additional contents of articles of statutory close corporations) to qualify it as a statutory close corporation has been breached. Statement of Cure of Breach: No breach of the provision included in its Articles pursuant to 15 Pa.C.S. § 2304(a) (relating to additional contents of articles of statutory close corporations) to qualify it as a statutory close corporation exists. American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-2309A/2309B–2 IN TESTIMONY WHEREOF, the undersigned corporation has caused this Statement of Breach of Qualifying Condition/Statement of Cure of Breach of Qualifying Condition to be signed by a duly authorized officer thereof this day of , . Name of Corporation Signature Title American LegalNet, Inc. www.FormsWorkFlow.com Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 web site: www.dos.state.pa.us/corps General Instructions for Completion of Form: A. Typewritten is preferred. If not, the form shall be completed in black or blue-black ink in order to permit reproduction. The filing fee for this form is $70 made payable to the Department of State. 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. This form and all accompanying documents shall be mailed to the address listed above. Instruction for Statement of Breach of Qualifying Condition Only E. Under 15 Pa.C.S. § 2309(a)(1) this form shall be filed within 30 days after the occurrence of the event amounting to a "public offering" of any of the shares of any class of the corporation within the meaning of the Securities Act of 1933 (15 U.S.C. § 77a et seq.), or within 30 days after the event has been discovered, whichever is later. The corporation shall within the same period furnish a copy of this form to each shareholder. F. Under 15 Pa.C.S. § 2309(a)(2) the corporation is required concurrently with filing of this form to take such steps as are necessary to correct the situation. When the situation has been remedied this form shall be filed under the direction of Statement of Cure of Breach of Qualifying Condition. American LegalNet, Inc. www.FormsWorkFlow.com