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Statement with respect to shares for a Domestic Business Corporation (Pennsylvania)

This form is to change a registered office in Pennsylvania. The form registers the name of the corporation, registered agent and address. The form provided here is simply a sample of what the actual Form 1507, 6144, 4144, 8506 and 5507 look like.

PENNSYLVANIA DEPARTMENT OF STATE CORPORATION BUREAU

Statement with Respect to Shares
Domestic Business Corporation
(15 Pa.C.S. § 1522)

Name _____________________________

Address ___________________________

City _______________________________

State ______________________

Zip Code __________________

Document will be returned to the name and address you enter

In compliance with the requirements of 15 Pa.C.S. § 1522(b) (relating to statement with respect to shares), the undersigned corporation, desiring to state the designation and voting rights, preferences, limitations, and special rights, if any, of a class or series of its shares, hereby states that:

1. The name of the corporation is: _____________________________

2. Check and complete one of the following:
____ The resolution amending the Articles under 15 Pa.C.S. § 1522(b) (relating to divisions and determinations by the board), set forth in full, is as follows: ________________________________

____ The resolution amending the Articles under 15 Pa.C.S. § 1522(b) is set forth in full in Exhibit A attached hereto and made a part hereof.

3. The aggregate number of shares of such class or series established and designated by (a) such resolution, (b) all prior statements, if any, filed under 15 Pa.C.S. § 1522 or corresponding provisions of prior law with respect thereto, and (c) any other provision of the Articles is ______________ shares.

4. The resolution was adopted by the Board of Directors or an authorized committee thereon on: _______________________________

5. Check, and if appropriate complete, one of the following:

____ The resolution shall be effective upon the filing of this statement with respect to shares in the Department of State.

____ The resolution shall be effective on: _______________ (Date) at __________ (Hour).

IN TESTIMONY WHEREOF, the undersigned corporation has caused this statement to be signed by a duly authorized officer thereof this__________________ day of ________________, _________.

________________________________________________ Name of Corporation

________________________________________________ Signature

________________________________________________ Title


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INSTRUCTIONS FOR FILLING OUT THIS FORM
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Department of State
Corporation Bureau
P.O. Box 8722
Harrisburg, PA 17105-8722
(717) 787-1057
Web site: www.dos.state.pa.us/corps

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 $70 made payable to the Department of State.

B. A separate form shall be submitted for each class or series of shares affected. If a number of classes or series of shares are affected at the same time, consideration should be given to filing form DSCB:15-1915/5915 (Articles of Amendment-Domestic Corporation).

C. The effective date in Paragraph 5 may not be prior to the filing date, but the resolution may state a prior effective date "for accounting purposes only."

D. If the corporation was incorporated on or after October 1, 1989, the words "or corresponding provisions of prior law" may be omitted from Paragraph 3.

E. This form and all accompanying documents shall be mailed to the address stated above.

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