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Charitable Organization Registration Statement Form - Wisconsin Department Of Safety And Professional Services Page 3

Wisconsin Department of Safety and Professional Services

12.

List all officers, directors, trustees and executive personnel. MARK IN THE FIRST COLUMN ALL

INDIVIDUALS WHO ARE RESPONSIBLE FOR DECIDING HOW CONTRIBUTIONS WILL BE USED.

Use a separate sheet if necessary.

NAME

ADDRESS

TITLE

13.

List the names of the person(s) within your organization who have final responsibility for the custody of

contributions received by your organization (who is responsible for deposit and withdrawal of funds to/from

bank account). Use a separate sheet if necessary.

NAME

ADDRESS

TITLE

CERTIFICATION:

We certify that the information furnished in this statement and all continuation

sheets are true and correct to the best of our knowledge.

TWO DIFFERENT NOTARIZED SIGNATURES ARE REQUIRED BY LAW.

________________________

______________________________________________________

Date

Signature of President or Authorized Officer

Subscribed and sworn before me this _______________ day of ________________________ , ___________ .

_____________________________________________

_____________________________________

Signature of Notary Public

(Seal)

Date Commission Expires

________________________

______________________________________________________

Date

Signature of Chief Fiscal Officer

Subscribed and sworn before me this _______________ day of ________________________ , ___________ .

_____________________________________________

_____________________________________

Signature of Notary Public

(Seal)

Date Commission Expires

#296 (Rev. 8/13)

Ch. 440.41, Stats.

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Committed to Equal Opportunity in Employment and Licensing

Charitable Organization Registration Statement Form - Wisconsin Department Of Safety And Professional Services Page 3