15-134B Docketing statement changes

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PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS Part I. Complete for each filing: Current name of entity or association (survivor or new entity): Entity number, if known: __________________ Formation/foreign registration date in PA: __________________ State of formation: ________________________ Effective date, if any: ________________________ Part II. Check appropriate transaction: ____ Amendment (complete Section A) ____ Correction (complete Section A) ____ Merger (complete Section B) ____ Division (complete Section C) ____ Conversion (complete Sections A and D) ____ Abandonment (complete Section E) ____ Revival (complete Section F) ____ Domestication (complete Section G) ____ Dissolution before Commencement of Business (complete Section H) Section A Amendment or Correction - Complete fields which pertain to changes : Name____________________________________ ________________________________________ _________________ Registered Office.

DSCB:15-134B-2 Section C – Division - Complete Section A with any changes to the association surviving the division, if any Check only one: ____ Entity named in Part I survives ___ Entity named in Part I does not survive. Newly created entity(s) from the division are: (attach sheet for additional new entities) Name Entity Number

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