PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Statement of Correction DSCB:15-138 (rev. 7/1/2015) *138* 138 Return document by email to: _________________________________ Read all instructions prior to completing. This form may be submitted online at https://www.corporations.pa.gov/. Fee: $70 In compliance with the requirements of 15 Pa.C.S. § 138 (relating to statement of correction), the undersigned association or other person, desiring to correct an inaccurate, defective or erroneous record, hereby states that: 1. The name of the association or other person is: _________________________________________________________ 2. The current registered office address as on file with the Department of State. Complete part (a) OR (b) ­ not both: (a) _____________________________________________________________________________________________________ Number and street City State Zip County (b) c/o: __________________________________________________________________________________________________ Name of Commercial Registered Office Provider County 3. The statute by or under which the association was formed (or the preceding filing was made, in the case of a filing that does not constitute a part of the public organic record of an association) is: ___________________________________ 4. The inaccuracy or defect to be corrected is (include Department of State form name and date filed): 5. Check one of the following: The portion of the document requiring correction in corrected form is set forth in Exhibit A attached hereto. The original document to which this statement relates shall be deemed re-executed. The original document to which this statement relates shall be deemed stricken from the records of the Department. IN TESTIMONY WHEREOF, the undersigned association or other person has caused this Statement of Correction to be signed by a duly authorized officer thereof or otherwise in its name this ______________ day of ____________________________, 20_______. ______________________________________ Name of Association ___________________________________________________ Signature ___________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-138 - Instructions Pennsylvania Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 web site: www.dos.pa.gov/corps General Information Typewritten is preferred. If handwritten, the form must be legible and completed in black or blue-black ink in order to permit reproduction. The nonrefundable filing fee for this form is $70. Checks should be made payable to the Department of State. Checks must contain a commercially pre-printed name and address. This form and all accompanying documents shall be mailed to the address stated above. Applicable Law See 15 Pa.C.S. § 138 for general information on Statement of Correction. Statutes are available on the Pennsylvania General Assembly website, www.legis.state.pa.us, by following the link for Statutes. Who should file this form? Whenever any document authorized or required to be delivered to the Department of State for filing has been so filed and is an inaccurate record of the action therein referred to or was defectively or erroneously executed, the document may be corrected by delivering to the Department for filing a Statement of Correction. Only documents that have already taken effect may be corrected under this section. If a document has not yet taken effect, it may be abandoned under 15 Pa.C.S. § 141 if the requirements of that section are satisfied. Otherwise, the document must be amended in accordance with the applicable provisions of this title or, if the document relates to the formation of an entity, the existence of the entity may be terminated in accordance with the applicable provisions of law. A Statement of Correction may not be used as an alternative to the dissolution process. Thus, a Statement of Correction may not be used to strike the original public organic record (such as Articles of Incorporation) from the records of the Department. See 15 Pa.C.S. § 138(b)(2). Attachments The following, in addition to the filing fee, shall accompany this form: (1) One copy of a completed form DSCB:15-134B (Docketing Statement - Changes) with respect to each form, if any, which accompanied the original filing. filing is to be returned by email, an email address must be provided. An email will be sent to address provided, containing a link and instructions on how a copy of the filed document or correspondence may be downloaded. Any email or mailing addresses provided on this form will become part of the filed document and therefore public record. 1. Give the exact name of the association. The name on this line must match exactly the association name as provided in the document sought to be corrected and in the Department's records at the time this Statement of Correction is submitted for filing. This field is required. 2. Current address. The address provided must be the association's registered office address (a) or Commercial Registered Office Provider (b) as on file with the Department of State at the time this Statement of Correction is submitted for filing. This field is required. 3. Supply the statute by or under which the association was formed, or the preceding filing was made, in the case of a filing that does not constitute a part of the public organic record of an association. Example: Business Corporation Law of 1988, Limited Liability Company Law of 1994. This field is required. 2. The type of document to be abandoned is the name of the form or document previously submitted, which has not yet become effective: Statement of Merger, Articles of Incorporation, etc. This field is required. 3. The date is the date the document sought to be abandoned was delivered to the Department for filing. This field is required. 4. Identify the inaccuracy or defect to be corrected. This should identify the defective document by specifying its name and DSCB form number, the filing date of the defective document and a statement of the defect to be corrected. This field is required. Signature and Verification The Statement of Correction must be signed by the association or other person that delivered the inaccurate, erroneous or defective document for filling. Signing a document delivered to