PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Statement of Domestication (15 Pa.C.S. § 161) Statement of Contingent Domestication-Other (15 Pa.C.S. § 162E) Document will be returned to the name and address you enter to the left. Name Address City State Zip Code Fee: $125 - Domestication $1500 – Contingent Domestication In compliance with the requirements of the applicable provisions (relating to domestication of certain alien associations/ contingent domestication of certain foreign associations), the undersigned entity, desiring to become a domestic association/contingent domestic association, hereby states that: 1. The name of the entity is: 2. The name of the jurisdiction under the laws of which it was first formed, incorporated or otherwise came into being is: 3. The date on which it was first formed, incorporated or otherwise came into being is: 4. The name of the jurisdiction that constituted the seat, siege social or principal place of business or control administration of the entity, or any equivalent under applicable law, immediately prior to the filing of this statement was: 5. Upon domestication the entity will be a domestic association under the laws of the Commonwealth of Pennsylvania. American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-161/162E-2 Statement of Domestication: complete paragraph 6 6. The filing of this statement and the renunciation of the prior domicile of the undersigned entity have been authorized by a majority in interest of the shareholders, members or other proprietors of the entity or by any greater vote required by its charter or other organic documents. Statement of Contingent Domestication-Other: complete paragraphs 7 and 8 7. The effectiveness of this Statement of Contingent Domestication is contingent upon the subsequent filing of a Statement of Consummation of Domestication. 8. The filing of this Statement of Contingent Domestication and the delegation of authority to file a Statement of Consummation of Domestication on behalf of the undersigned entity has been authorized by a majority in interest of the shareholders, members or other proprietors of the entity or by any greater vote required by its charter or other organic documents. IN TESTIMONY WHEREOF, the undersigned entity has caused this statement to be executed this day of , . Name of Entity 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 General 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 fee for filing a Statement of Domestication is $125 and the fee for filing a Statement of Contingent Domestication-Other is $1500 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. This form may be filed by an (alien) entity, such as an (alien) sole proprietorship which is not an association as defined in 15 Pa.C.S. § 102 (relating to definitions). D. This form shall be executed in the English language. E. 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. F. The statement may be executed on behalf of the entity by any authorized person. G. This form and all accompanying documents shall be mailed to the address stated above. Instructions for Statement of Domestication Only: I. The following, in addition to the filing fee, shall accompany this form: One copy of a completed form DSCB:15-134A (Docketing Statement). J. This form may not be filed by any association eligible to file form DSCB:15-4161/6161 (Articles of DomesticationForeign Corporation Instructions for Statement of Contingent Domestication-Other Only: K. The following, in addition to the filing fee, shall accompany this form: (1) One copy of a completed form DSCB:15-134A (Docketing Statement). (2) Any necessary copies of form DSCB:17.2.3 (Consent to Appropriation of Name). However, the filing of this form will not prevent another association from later appropriating the name in view of the confidentiality provisions of 15 Pa.C.S. § 162 (a). (3) Any necessary Pennsylvania governmental approvals. L. This form may not be filed by any association eligible to file DSCB:15-162A/162B/162C/162D (Statement of Contingent Domestication-Foreign Business/Nonprofit Corporation/Limited Partnership/Limited Liability Company) or by any entity governed by the laws of the United States, any state, Puerto Rico or any possession or territory of the United States. M. 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). American LegalNet, Inc. www.FormsWorkFlow.com