PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Decennial Report of Association Continued Existence (54 Pa.C.S. § 503) Document will be returned to the name and address you enter to the left. Name Address City State Zip Code Fee: $70 In compliance with the requirements of 54 Pa.C.S. § 503 (relating to decennial filings required) the undersigned association hereby states that: 1. The name of the association to which this report relates is: ________________________________________________________________________________________ 2. The address of this association’s current registered office in the Commonwealth or name of its commercial registered office provider and the county of venue is: _________________________________________________________________________________________ Number and Street/Commercial Registered Office Provider City State Zip County 3. Complete part A or B if applicable: A. The address to which the registered office of the association in this Commonwealth is to be changed to: __________________________________________________________________________________________ Number and Street City State Zip County B. The registered office of the association shall be provided by: ___________________________________________________________________________________________ Name of Commercial Registered Office Provider County 4. The association has not made any filing in the Department from January 1, 2002 through December 31, 2011, in accordance with 54 Pa.C.S. § 503(b). 5. The Association continues to exist. IN TESTIMONY WHEREOF, the undersigned association has caused this Decennial Report of Association Continued Existence to be signed by a duly authorized officer this _______ day of ______________, 20___. _______________________________________________________ Name of Association _______________________________________________________ Signature Rev. 11/2010 _______________________________________________________ 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 ink in order to permit reproduction. The filing fee for this form is $70 with check or money order made payable to the Department of State. B. The entity name as identified in the records of the Department of State Corporation Bureau has been entered in Item 1. If the name has been changed, an Amendment form must be filed separately to effect this change on the Department’s records. C. The registered office as identified in the records of the Department of State Corporation Bureau has been entered in Item 2. If the address has been changed, the current registered office or Commercial Registered Office Provider and County of Venue should be identified in Item 3. 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. D. In accordance with 54 Pa.C.S. § 503(b), no filing of this form is required if the association has made any filing in the Department from January 1, 2002 through December 31, 2011, other than a decennial report, application for registration of fictitious name, consent to appropriation of name, name searches or name reservations. Additionally, no filing of this form is required if the association has had officer information forwarded to the department by the Department of Revenue from January 1, 2002 through December 31, 2011, under 15 Pa.C.S. § 1110 (relating to annual report information). E. This form and all accompanying documents shall be mailed to the address shown above. American LegalNet, Inc. www.FormsWorkFlow.com