PENNSYLVANIA DEPARTMENT OF STATE CORPORATION BUREAU Decennial Report ___ Insignia (54 Pa.C.S. §1314) ___ Mark Used with Articles or Supplies (54 Pa.C.S. §1515) Document will be returned to the name and address you enter to the left. Name Address City State Zip Code Fee: $70 In compliance with the requirements of 54 Pa.C.S. §1314 and §1515 (relating to decennial filings required) the undersigned organization/person having heretofore duly registered its insignia/mark used with articles or supplies in this Commonwealth and desiring to continue such registration, hereby states that: 1. The name of the registrant is: _________________________________________________________________________________________ 2. The residence, location or place of business of the registrant is: _________________________________________________________________________________________ Number and Street City State Zip County 3. Complete if applicable: The address to which the residence, location or place of business of the registrant is to be changed: __________________________________________________________________________________________ Number and Street City State Zip County 4. The date on which the last preceding filing was made in the Department with respect to the insignia/mark is: ____________________________________ 5. Check one of the following: ___ The insignia shall continue to be registered in the Department. ___ The mark continues to be used in connection with the articles or supplies specified in the registration. IN TESTIMONY WHEREOF, the undersigned registrant has caused this Decennial Report to be signed by a duly authorized officer this _______ day of ______________, 20___. _______________________________________________________ Name of Registrant _______________________________________________________ Signature Rev. 11/2010 _______________________________________________________ Title American LegalNet, Inc. www.FormsWorkFlow.com Department of State Corporation Bureau P.O. Box 8039 Harrisburg, PA 17105-8039 (717) 787-1057 web site: www.dos.state.pa.us/corps Instructions for Completion of Form: A. Typewritten is preferred. If not, the form shall be completed in black or blue ink in order to permit reproduction. The filing fee for this form is $70 with check or money order made payable to the Department of State. B. The registrant name as identified in the records of the Department of State Corporation Bureau has been entered in Item 1. If the name has been changed, an Amendment form must be filed separately to effect this change on the Department’s records. C. The registrant address as identified in the records of the Department of State Corporation Bureau has been entered in Item 2. If the address has been changed, the new address should be identified in Item 3. Under 15 Pa.C.S. § 135(c) (relating to addresses), an actual street or rural route box number must be used as an address, and the Department of State is required to refuse to receive or file any document that sets forth only a post office box address. D. In accordance with 54 Pa.C.S. §1314(b) and §1515(b), no filing of this form is required if the registrant has made any filing with respect to insignia/mark in the Department from January 1, 2002 through December 31, 2010, other than a decennial report. This Decennial Report shall be filed during the year 2011 and every tenth year thereafter (e.g. 2021, 2031, etc.) E. This form and all accompanying documents shall be mailed to the address shown above. American LegalNet, Inc. www.FormsWorkFlow.com