Form 11a - Professional Solicitor'S Annual Financial Report (Page 4 of 4) in pdf

Form 11a - Professional Solicitor'S Annual Financial Report Page 4

Form 11A

Certification by the Solicitor:

Under the pains and penalties of perjury, I certify that the information contained in this report and the

attached financial report is accurate and complete to the best of my knowledge.

Signature on behalf of Professional Solicitor

PRINT name and title

Date signed

Subscribed and sworn to me this

day of

, 20

Signature of Notary Public

Affix seal here

Date signed

Certification by the Charitable Organization:

Under the pains and penalties of perjury, I certify that the information contained in this report and the

attached financial report is accurate and complete to the best of my knowledge.

Signature of authorized officer or trustee

PRINT name and title

Date signed

Subscribed and sworn to me this

day of

, 20

Signature of Notary Public

Affix seal here

Date signed

Under the pains and penalties of perjury, I certify that the information contained in this report and the

attached financial report is accurate and complete to the best of my knowledge.

Signature of authorized officer or trustee

PRINT name and title

Date signed

Subscribed and sworn to me this

day of

, 20

Signature of Notary Public

Affix seal here

Date signed

***Please note that the signatures of two different officers on behalf of the charitable organization

are required. The Form 11A will not be accepted without the appropriate notarized signatures.

Form 11A

Page 4 of 4

Rev. 07/2007

Form 11a - Professional Solicitor'S Annual Financial Report Page 4