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Request To Withdraw Executive Law Registration Form - New York Office Of The Attorney General

TATE OF

ORK

FFICE OF THE

TTORNEY

ENERAL

HARITIES

UREAU

120 B

, N

, NY 10271

ROADWAY

ORK

REQUEST TO WITHDRAW EXECUTIVE LAW REGISTRATION

CHAR005

Attorney General's registration number(s): Exec. Law _________

EPTL __________

Organization's name: __________________________________________

Mailing address: ______________________________________________

______________________________________________

State of

)

County of

)ss.

I swear under oath that the organization listed above

1. Is no longer soliciting contributions from New York State

residents,

2. Does not receive over $25,000 in contributions per year,

____ Does not use the services of a Professional Fund Raiser

to solicit contributions in New York.

____ Does not receive government grants totaling over

$25,000 per year.

NAME (Printed)

TITLE

___________________________

SIGNATURE

___________________________

Daytime telephone number

Sworn to before me this

day of,_______, 20__

_______________________

NOTARY PUBLIC

(Rev. 7\99)

Request To Withdraw Executive Law Registration Form - New York Office Of The Attorney General