PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Statement of Merger, Consolidation or Division Qualified Foreign Corporation (15 Pa.C.S.) Foreign Business Corporation (§ 4127) Foreign Nonprofit Corporation (§ 6127) Document will be returned to the name and address you enter to the left. Name Address City State Zip Code Fee: $150 plus $40 for each additional party In compliance with the requirements of the applicable provisions of 15 Pa.C.S. (relating to corporations and unincorporated associations), the undersigned corporation, which is the corporation surviving or a new corporation resulting from a statutory merger, consolidation or division to which a qualified foreign corporation was a non-surviving party, hereby states that: 1. The non-surviving qualified foreign corporation(s) which was a party (were parties) to the statutory merger, consolidation or division is (are): Name Jurisdiction Date Certificate of Authority was filed in PA. 2. Check one of the following: The corporate existence of the corporation(s) named in the foregoing paragraph has (have) been terminated by: Merger Consolidation Division American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-4127/6127-2 3. Strike out this paragraph if the transaction was a merger and the surviving corporation is a qualified foreign business corporation. Attached hereto and made a part hereof as Exhibit A is a completed form DSCB:15-4124/6124 (Application for a Certificate of Authority-Foreign Corporation) with respect to each foreign corporation resulting from or surviving the merger, consolidation or division. IN TESTIMONY WHEREOF, the undersigned corporation has caused this Statement of Merger, Consolidation or Division to be signed by a duly authorized officer thereof this day of , . Name of Surviving 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 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 $150 plus $40 for each qualified foreign corporation named therein, made payable to the Department of State. B. The following, in addition to the filing fee, shall accompany this form: (1) Two copies of completed form DSCB:15-134B (Docketing Statement-Changes) with respect to each qualified foreign corporation named in Paragraph 1. (2) If form DSCB:15-4124/6124 (Application for a Certificate of Authority-Foreign Corporation) is attached, copies of any documents and one copy of completed form DSCB:15-134A (Docketing Statement) as required by the instructions of that form. C. It is not necessary to execute the form DSCB:15-4124/6124 attached as Exhibit A or to submit to the Department the original or an amended certificate of authority for cancellation. The filing fee specified for this form includes the filing of such Exhibit A and an additional fee relating to form DSCB:15-4124/6124 should not be tendered. D. If a domestic corporation is a party to the transaction described in the introduction to this form, this form should not be filed. E. This form is applicable only where the qualified foreign corporation is a nonsurviving party to a transaction not effected by a filing in the Department. If a qualified foreign corporation is a surviving party to a transaction not effected by a filing in the Department, form DSCB:15-4126/6126 (Application for an Amended Certificate of Authority-Foreign Corporation) should be filed by the qualified foreign corporation, but only if the name of the corporation is changed by the merger or division. F. Under 15 Pa.C.S. §§ 4127(b) and 6127(b) upon the filing of this form any applicant corporation named in form DSCB:15-4124/6124 attached as Exhibit A shall be deemed to hold a certificate of authority, and no actual certificate will be issued to the applicant by the Department. G. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkFlow.com