Short Form Pc, Schedule A-2, Certification By Organization - 2009 Page 3

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Identify the individuals who will have final responsibility for the charity’s custody of contributions.
Name and Title:
Address:
City:
State:
Zip:
Name and Title:
Address:
City:
State:
Zip:
Name and Title:
Address:
City:
State:
Zip:
Identify the individuals who will have final responsibility for the charity’s distribution of contributions.
Name and Title:
Address:
City:
State:
Zip:
Name and Title:
Address:
City:
State:
Zip:
Name and Title:
Address:
City:
State:
Zip:
Short Form PC – Schedule A-2
Page 3 of 4
Rev. 05/2009

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