Statement Of Termination Of Registration Of Association Name
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Statement Of Termination Of Registration Of Association Name Form. This is a Pennsylvania form and can be use in Fictitious Names Department Of State.
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PENNSYLVANIA DEPARTMENT OF STATE
CORPORATION BUREAU
Statement of Termination
of Registration of Association Name
(54 Pa.C.S. § 506)
Name
Address
Document will be returned to the
name and address you enter to
the left.
⇐
City
State
Zip Code
Fee: $70
In compliance with the requirements of 54 Pa.C.S. § 506 (relating to voluntary termination of registration by corporations and
other associations), the undersigned association, desiring to terminate the registration of its name with the Department of State, hereby
states that:
1.
The name of the association is:
2. The (a) address of this association’s present registered office in this Commonwealth or (b) name of its commercial
registered office provider and the county of venue is:
(a) Number and Street
City
State
Zip
(b) Name of Commercial Registered Office Provider
c/o:
County
County
3. The name of the association was registered on
under the following statute:
Date
.
4. The registration of the name of the association under 54 Pa.C.S. Ch.5 (relating to corporation and other association
names) is hereby terminated.
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DSCB:54-506-2
IN TESTIMONY WHEREOF, the undersigned association
has caused this Statement of Termination of Registration of
Name to be signed by a duly authorized officer this
day of
,
.
Name of Association
Signature
Title
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Department of State
Corporation Bureau
P.O. Box 8722
Harrisburg, PA 17105-8722
(717) 787-1057
web site: www.dos.state.pa.us/corps
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. The applicable statute to be inserted in Paragraph 3 should be determined by reference to the basis of registration set
forth in 54 Pa.C.S. § 501(a) (relating to register established).
D. This form and all accompanying documents shall be mailed to the address stated above.
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