Form Ss-6058 - Summary Of Financial Activities Of An Exempt Charitable Organization (Page 2 of 2) in pdf

Form Ss-6058 - Summary Of Financial Activities Of An Exempt Charitable Organization Page 2

SIGNATURE SECTION

This document must bear the notarized signature of two (2) authorized officers of the organization.

We certify that the information furnished in this Request for Exemption and all continuation sheets is

true and correct to the best of our knowledge.

___________________________ _________________

____________________________ ________________

Signature of Authorized Officer

Date Signed

Signature of Authorized Officer

Date Signed

______________________________________________

_____________________________________________

Print Name (Clearly)

______________________________________________

_____________________________________________

Title

NOTARY SEAL

Sworn to and subscribed before me (or to me personally

known) at:

______________________________________________

_____________________________________________

(County and State)

This the _____ day of ___________________ 200__

This the _____ day of ____________________200__

______________________________________________

_____________________________________________

Signature of Notary Public

My Commission Expires:_____________________

OFFICIAL USE ONLY

Auditor/Reviewer Initials: ___________

Date Reviewed:

___________

Documents Attached:

___________

Comments:

___________________________________________________________________________________

SS-6058 (Rev 3/02)

RDA 1745

Form Ss-6058 - Summary Of Financial Activities Of An Exempt Charitable Organization Page 2