Short Form Pc, Schedule A-2, Certification By Organization - 2009 Page 4

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C
o
ertiFiCation BY
rganization
Two different signatures required. Signers must be organization president or other authorized officer or trustee.
Under penalty of perjury, we declare that the information furnished in this report, including all attachments, is
true and correct to the best of our knowledge.
Signature:
Date:
Print Name:
Title:
Signature:
Date:
Print Name:
Title:
Short Form PC
Page 4 of 4
Rev. 05/2009

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