PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Statement of Consummation of Domestication (15 Pa.C.S. § 162F) 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 15 Pa.C.S. § 162(f) (relating to statement of consummation of domestication), the undersigned entity, desiring to consummate its domestication, hereby states that: 1. The name of the entity is: 2. Check one of the following: An emergency condition exists in the jurisdiction the law of which governs the internal affairs of the entity and in the judgment of the management of the entity a temporary transfer of the domicile of the entity to the Commonwealth of Pennsylvania is warranted by the circumstances. An event has occurred that, under the law of the jurisdiction governing the internal affairs of the entity, permits the entity to transfer its domicile. IN TESTIMONY WHEREOF, the undersigned entity has caused this Statement of Consummation of Domestication to be executed this __________ day of _________________,___________. Name of Entity Signature Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-162F 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 $70 made payable to the Department of State. B. This form may be filed in the Department by electronic mail, facsimile transmission, telex or other similar means of communication. C. If the name of the entity is in a foreign language, the name as set forth in Paragraph 1 shall be set forth in Roman letters or characters or in Arabic or Roman numerals. D. The notice may be executed on behalf of the entity by any authorized person. E. Annual renewal.-A renewal application may be filed between October 1 and December 31 in each year and shall extend the applicability of this section for the following calendar year. Otherwise the association shall not be entitled to any benefits of this section. See section 153(a)(14) (relating to contingent domestication). F. This form and all accompanying documents shall be mailed to the address stated above. American LegalNet, Inc. www.FormsWorkFlow.com