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. This form may be submitted online at https://www.corporations.pa.gov/. Fee: $125 I qualify for a veteran/reservist-owned small business fee exemption (see instructions) In compliance with the requirements of 15 Pa.C.S. § 8821 (relating to certificate of organization), the undersigned desiring to organize a limited liability company, hereby certifies that: 1. The name of the limited liability company is: ___________________________________________________ (designator is required, e.g., "company," "limited" or "limited liability company" or any abbreviation thereof) 2. Complete part (a) or (b) ­ not both: (a) The address of this limited liability company's registered office in this Commonwealth is: (post office box alone is not acceptable) Number and Street City State Zip County (b) The name of this limited liability company's commercial registered office provider and county of venue is: c/o: Name of Commercial Registered Office Provider County 3. The name of each organizer is (all organizers must sign on page 2): 4. Effective date of Certificate of Organization (check, and if appropriate complete, one of the following): The Certificate of Organization shall be effective upon filing in the Department of State. The Certificate of Organization shall be effective on: ________________________ at ______________. Date (MM/DD/YYYY) Hour (if any) American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-8821-2 5. Restricted professional companies only. Check the box if the limited liability company is organized to render a restricted professional service and check the type of restricted professional service(s). The company is a restricted professional company organized to render the following restricted professional service(s): Chiropractic Dentistry Law Medicine and surgery Optometry Osteopathic medicine and surgery Podiatric medicine Public accounting Psychology Veterinary medicine 6. Benefit companies only. Check the box immediately below if the limited liability company is organized as a benefit company: This limited liability company shall have the purpose of creating general public benefit. Optional specific public benefit purpose. Check the box immediately below if the benefit company is organized to have one or more specific public benefits and supply the specific public benefit(s). See instructions for examples of specific public benefit. This limited liability company shall have the purpose of creating the enumerated specific public benefit(s): 7. For additional provisions of the certificate, if any, attach 8˝ x 11 sheet(s). IN TESTIMONY WHEREOF, the organizer(s) has (have) executed this Certificate of Organization this __________ day of _____________________________, 20 . ______________________________________________________________ Signature ______________________________________________________________ Signature ______________________________________________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com DSCB:15-8821­Instructions 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 $125. Checks should be made payable to the Department of State. Checks must contain a commercially pre-printed name and address. Filers requesting a veteran/reservist-owned small business fee exemption should attach proof of the veteran's or reservist's status to the Certificate of Organization form when submitted. For more information on the fee exemption, see Fees and Payments. This form and all accompanying documents shall be mailed to the address stated above. Who should file this form? One or more persons acting as organizers to form a limited liability company must file a certificate of organization in the Department of State. Applicable Law See 15 Pa.C.S. § 8821 for general information on Formation of Limited Liability Company and Certificate of Organization. Statutes are available on the Pennsylvania General Assembly website, www.legis.state.pa.us, by following the link for Statutes. See also 15 Pa.C.S. § 8898 and § 8998 for provisions on annual reports/registrations that are required of benefit companies and restricted professional companies, respectively. Limited Liability Company Name Requirements Generally, the name of an association may not be the same as the name of another association which is already on the records of the Department of State. Depending on the type of association, certain designators must be used in the association name. Designators are the words or abbreviations used at the end of the association name which designate the type of association. The minimum requirements for limited liability company names can be found at 15 Pa.C.S. §§ 201, 202 and 204. The name of a domestic limited liability company must contain: (1) the term "company," "limited" or "limited liability comp any" or an abbreviation of one of those terms, or (2) words or abbreviations of like import used in a jurisdiction other than this Commonwealth. The name of a limited liability company may not contain any words implying that it is a business corporation, such as "corporation" or "incorporated" or an abbreviation of these terms. Restricted words and/or approvals: Association names may not contain words, phrases or abbreviations prohibited or restricted by statute or regulation, unless in compliance with the restriction, generally with the consent or approval of a government agency, board or commission. These may include certain professional and occupational boards or commissions of the Bureau of Professional and Occupational Affairs, the Department of Education, the Department of Banking and Securities, the Insurance Department or the Public Utility Commission. There are also words and abbreviations that may be restricted, prohibited, or may be permitted in certain instances as provided in various federal statutes, Attorney General opinions and Bureau regulations. Attachments The following, in addition to the fi