PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Return document by mail to: Name Address City State Zip Code Return document by email to: _________________________________ Read all instructions prior to completing. Fee: $70 In compliance with the requirements of 15 Pa.C.S. § 8898 (relating to annual benefit report), the undersigned benefit company hereby states that: 1. The name of the limited liability company is: ____________________________________________________________________________________________________ 2. Complete part (a) or (b) ­ not both: (a) The address of this limited liability company's current registered office in this Commonwealth is ____________________________________________________________________________________________________ Number and Street City State Zip County (b) The name of this limited liability company's commercial registered office provider and the county of venue is: c/o:_________________________________________________________________________________________________ Name of Commercial Registered Office Provider County 3. A narrative description of: (i) the ways in which the benefit company pursued general public benefit during the year and the extent to which general public benefit was created; ____________________________________________________________________________________________________ (ii) the ways in which the benefit company pursued any specific public benefit that the certificate of organization states is the purpose of the benefit company to create and the extent to which that specific public benefit was created; ____________________________________________________________________________________________________ (iii) any circumstances that have hindered the creation by the benefit company of general or specific public benefit; and ____________________________________________________________________________________________________ (iv) the process and rationale for selecting or changing the third-party standard used to prepare the benefit report. ____________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-8898 - 2 4. An assessment of the overall social and environmental performance of the benefit company against a third-party standard applied consistently with any application of that standard in prior benefit reports or accompanied by an explanation of the reasons for any inconsistent application. 5. A statement of any connection between the organization that established the third-party standard, or its directors, officers or any holder of 5% or more of the governance interests in the organization, and the benefit company or its members, managers or officers or any holder of 5% or more of the outstanding interests in the benefit company, including any financial or governance relationship which might materially affect the credibility of the use of the third-party standard. IN TESTIMONY WHEREOF, the undersigned benefit limited liability company has caused this Annual Benefit Report to be signed by a duly authorized officer this _______ day of _________________, 20______. _______________________________________________________ Name of Company _______________________________________________________ Signature _______________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-8898 ­ Instructions Pennsylvania Department of State Bureau of Corporations and Charitable Organizations P.O. Box 8722 Harrisburg, PA 17105-8722 (717) 787-1057 Website: 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, including any necessary governmental approvals, shall be mailed to the address stated above. Who should file this form? Every domestic limited liability which is a benefit company must deliver to each member an annual benefit report. Concurrently with the delivery of the benefit report to members, the benefit company must deliver a copy of the benefit report to the Department of State for filing Applicable Law For annual benefit report requirements, see 15 Pa.C.S. § 8898. Statutes are available on the Pennsylvania General Assembly website, www.legis.state.pa.us, by following the link for Statutes. Definitions A benefit company is a limited liability company that has elected to become subject to Chapter 88, Subchapter I of the Pennsylvania Uniform Limited Liability Company Act of 2016. A benefit company shall have a purpose of creating general public benefit. This purpose is in addition to its purpose under 15 Pa.C.S. § 8818(b) (relating to characteristics of limited liability company). The certificate of organization of a benefit company may identify one or more specific public benefits that it is the purpose of the benefit company to create in addition to its general public benefit purpose under 15 Pa.C.S. § 8894(a) and its purpose under 15 Pa.C.S. § 8818(b). 1. Give the exact name of the limited liability company. The name on this line must match exactly the association name as shown in Department's records at the time the Annual Benefit Report is submitted for filing. This field is required. 2. Current address. The address provided must be the company's registered office address (a) or Commercial Registered Office Provider (b) as on file with the Department of State at the time the Annual Benefit Report is submitted for filing. This field is required. 3 - 5. See 15 Pa.C.S. § 8898 for more information. Additional pages may be attached as needed. A benefit company may change from year to year the standard it uses for assessing its performance. But if a benefit company uses the same standard for assessing its performance in more than one year, the standard must either be applied consistently or the benefit company must provide an explanation of the reasons for any inconsistent use of the standard. Fields 3-5 are required with the exception that any financial or proprietary information may be omitted from the benefit report as filed with the Department of State. Signature and Verification An authorized representative of the be