PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Statement of Termination of Domestication (15 Pa.C.S. § 162G) Application for Renewal of Contingent or Temporary Domestication Status (15 Pa.C.S. § 162H) Document will be returned to the name and address you enter to the left. Name Address City State Zip Code Fee: $1500 - Termination $1500 – Renewal/Temporary In compliance with the requirements of the applicable provisions (relating to statement of termination of domestication/relating to annual renewal), the undersigned entity, desiring to terminate/renew its status as a contingent domestic association or its temporary domiciliary status, hereby states that: 1. The name of the entity in the form set forth in the prior filings under 15 Pa.C.S. § 162 is: Statement of Termination of Domestication: complete paragraphs 2, 3 and 4 2. Strike out if inapplicable: The entity elects to terminate its domicile in this Commonwealth. 3. The Statement of Contingent Domestication is reinstated pending the filing in the Department of State a new Statement of Consummation of Domestication. 4. The Statement of Contingent Domestication is withdrawn. Application for Renewal of Contingent or Temporary Domestication Status: complete paragraph 5 5. Check one of the following: Its status as a contingent domestic association is hereby renewed. Its temporary domiciliary status is hereby renewed. American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-162H-2 IN TESTIMONY WHEREOF, the undersigned entity has caused this Statement/Application 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/corp.htm 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 filing fee for this form is $1500 for Statement of Termination of Domestication and $1500 for Application for Renewal of Contingent or Temporary Domestication Status made payable to the Department of State B. This form and all accompanying documents shall be mailed to the address stated above. Instructions for Termination of Domestication Only D. This form may be filed in the Department by electronic mail, facsimile transmission, telex or other similar means of communication. 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. Paragraph 2 is applicable only if a Statement of Contingent Domestication has theretofore been filed by the entity and is then in effect. G. The statement may be executed on behalf of the entity by any authorized person. Instructions for Application for Renewal of Contingent or Temporary Domestication Status Only H. This form may be filed between October 1 and December 31 of the year preceding the renewal year. American LegalNet, Inc. www.FormsWorkFlow.com