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Form 10a - Form Of Addendum To Registration Statement To Be Filed By Professional Solicitors Page 6

Form 10A

Certification by the Solicitor:

Under penalties of perjury, I certify the above declarations to be true and correct to the best of my

knowledge. I agree to file supplemental Forms 10A if at any time the information on this form requires

amendment or correction. I agree to file the Professional Solicitor’s Annual Financial Report Form 11A

for the solicitation campaign which is the subject of this Form 10A as required by Massachusetts General

Laws Chapter 68, Section 25(c). I have attached a copy of the contract or written agreement that

corresponds to the above-referenced solicitation campaign as required by Massachusetts General Laws

Chapter 68, Section 22. I agree that no solicitation on behalf of the above-mentioned charitable

organization will commence prior to the filing of this Form 10A.

Under the pains and penalties of perjury, I certify the above declaration to be true and correct to the best

of my knowledge.

Signature on behalf of Professional Solicitor

PRINT name and title

Date signed

Acknowledgment by the Charitable Organization:

I acknowledge that I have reviewed the responses stated in this document on behalf of the charitable

organization:

(Name of charitable organization)

…and I declare, under penalties of perjury, that the responses are true and correct to the best of my

knowledge.

Signature of authorized officer or trustee

PRINT name and title

Date signed

Signature of authorized officer or trustee

PRINT name and title

Date signed

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

are required. The Form 10A will not be accepted without the appropriate signatures.

Form 10A

Page 6 of 6

Rev. 07/2007

Form 10a - Form Of Addendum To Registration Statement To Be Filed By Professional Solicitors Page 6