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: R
I
R
& A
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ECTION
OUR
EQUIRED FOR
NITIAL
EGISTRATION
NNUAL
EPORTING
BOARD OF DIRECTORS
SIGNATURES AND ACKNOWLEDGMENT
We, the undersigned, state and acknowledge that we are duly constituted officers of this organization,
being the ________________________ (Title) and _________________________ (Title) respectively, and
that we execute this document on behalf of the organization pursuant to the resolution of the
___________________________ (Board of Directors, Trustees, or Managing Group) adopted on the _____
day of ___________________, 20____, approving the contents of the document, and do hereby certify that
the ________________________________ (Board of Directors, Trustees or Managing Group) has assumed,
and will continue to assume, responsibility for determining matters of policy, and have supervised, and will
continue to supervise, the finances of the organization. We further state that the information supplied is
true, correct and complete to the best of our knowledge.
________________________________________
_________________________________________
Name
(Print)
Name
(Print)
________________________________________
_________________________________________
Signature
Signature
________________________________________
_________________________________________
Title
Title
________________________________________
_________________________________________
Date
Date
NOTICE
Documents required to be filed are public records. Please do not include social security
numbers, driver’s license numbers or bank account numbers on the documents filed with this
Office as they are not required, but could become part of the public records. A charitable
organization is not required to file a list of its donors. If it is included, it may become part of
the public file.
AG: #2394878-v1
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