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Annual Report of a Board Member of a Hospital or Medical Services Corporation (Tennessee)

This is an annual report of a hospital or medical services corporation in Tennessee. The form provided here is simply a sample of what the actual Form SS 4498 looks like.

For Office Use Only

(For-Profit Corporation into LLC)

Corporate Filings
312 Eighth Avenue North
6th Floor, William R. Snodgrass Tower
Nashville, TN 37243

Pursuant to the provisions of Section 48-21-111 of the Tennessee Business Corporation Act, the undersigned domestic for-profit corporation hereby adopts the following articles of conversion:

1. The corporation was converted to a limited liability company from a corporation.

2. The name and principal business address of the former corporation was:



3. The SOS Control Number of the former corporation (if known) is:


4. The Plan of Conversion is attached to these Articles of Conversion and is incorporated herein by reference.

5. Articles of Organization of the limited liability company which satisfy Section 48-205-101 of the Tennessee Limited Liability Company Act are included in the Plan of Conversion.

6. The terms and conditions of the conversion have been approved by the unanimous vote of the shareholders.

7. The number of members of the limited liability company at the date of conversion is


Signature Date _________________________________


Signer's Capacity _________________________________

Name ________________________________ (typed or printed)

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