PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Application for Amended Certificate of Authority Foreign Corporation (15 Pa.C.S.) Foreign Business Corporation (§ 4124) Foreign Nonprofit Corporation (§ 6124) Document will be returned to the name and address you enter to the left. Name Address City State Zip Code Fee: $250 In compliance with the requirements of the applicable provisions of 15 Pa.C.S. (relating to corporations and unincorporated associations), the undersigned foreign corporation, desiring to receive an amended certificate of authority, hereby states that: 1. The name under which the corporation currently holds a certificate of authority to do business within the Commonwealth of Pennsylvania is: 2. The name of the jurisdiction under the laws of which the corporation is incorporated is: 3. The address of its principal office under the laws of the jurisdiction in which it is incorporated is: Number and Street City State Zip 4. The (a) address of this corporation's 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 (b) Name of Commercial Registered Office Provider c/o: State Zip County County Check if applicable: The foregoing reflects a change in Pennsylvania registered office. American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-4126/6126-2 5. The corporation desires that its certificate of authority be amended to change or correct the following information: hereof. The amendment adopted by the corporation is set forth in full in Exhibit A attached hereto and made a part hereof. 6. If the amendment set forth in Paragraph 5 reflects a change in the name of the corporation to one not available for use in this Commonwealth, complete the following: The fictitious name which the corporation adopts for use in transacting business in this Commonwealth is: The corporation shall do business in Pennsylvania only under such fictitious name pursuant to the attached resolution of the board of directors under the applicable provisions of 15 Pa.C.S. (relating to corporations and unincorporated associations) and the attached form DSCB:54-311 (Application for Registration of Fictitious Name). 7. If the amendment set forth in Paragraph 5 reflects a change in the name of the corporation, check one of the following: The change of name reflects a change effected in the jurisdiction of incorporation Documents complying with the applicable provisions of 15 Pa.C.S. § 4123(b) or 6123(b) (relating to exception; name) accompany this application. IN TESTIMONY WHEREOF, the undersigned corporation has caused this Application for an Amended Certificate of Authority to be signed by a duly authorized officer thereof this day of , . Name of Corporation Signature Title Rev. 9/12 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 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 $250 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 following, in addition to the filing fee, shall accompany this form: (1) Two copies of a completed form DSCB:15-134B (Docketing Statement-Changes). (2) Any necessary copies of form DSCB:17.2.3 (Consent to Appropriation of Name). If Letter of Consent cannot be obtained, the applicant may file in the Department a resolution of its board of directors adopting a fictitious name for use in transacting business in the Commonwealth of Pennsylvania which fictitious name is distinguishable upon the record to the name of any conflicting profit or nonprofit corporation or other association and that is otherwise available for use by a domestic business or nonprofit corporation. See 15 Pa.C.S. §§ 4123(b)(1)(i) and 6123(b)(1)(i). An additional filing fee of $70 shall accompany form DSCB:54-311 (Application for Registration of Fictitious Name). (3) Any necessary governmental approvals. If required governmental approvals for the use of the name cannot be obtained, the applicant may file in the Department a resolution of its board of directors adopting a fictitious name that is otherwise available for use by a domestic business or nonprofit corporation. See 15 Pa.C.S. §§ 4123(b)(2) and 6123(b)(2). D. Where the name of the corporation does not comply with 19 Pa. Code § 23.3 (relating to business corporation names) or with 19 Pa. Code § 41.3 (relating to nonprofit corporation names) the corporation must adopt a corporate designator for use in Pennsylvania and set forth the resulting name in Paragraph 5. See also 19 Pa. Code § 17.41 (relating to foreign association names. E. This form and all accompanying documents shall be mailed to the address stated above. Under 15 Pa.C.S. §§ 4126(b) or 6126(b) upon the filing of this form the applicant corporation shall be deemed to hold an amended certificate of authority, and no actual amended certificate will be issued to the applicant by the Department. American LegalNet, Inc. www.FormsWorkFlow.com