Form Char005 - Request To Withdraw Executive Law Registration

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CHAR005
STATE OF NEW YORK
DEPARTMENT OF LAW
REQUEST TO WITHDRAW
CHARITIES BUREAU - REGISTRATION SECTION
EXECUTIVE LAW REGISTRATION
120 BROADWAY
NEW YOR K, NY 10271
Attorney General’s registration number:
Name of Registrant:
Mailing address:
Tel. No.:
Email Address:
I certify, under penalty for perjury, that the above-named registrant (check all that apply):
1. Is no longer soliciting contributions from New York State residents.
2. Does not receive over $25,000 in contributions per year from New
York State residents, including direct and indirect public support and
government grants; and
Does not use the services of a Professional Fund Raiser or Fund
Raising Counsel to solicit contributions in New York.
NAME (Printed)
TITLE
SIGNATURE
DATE
Daytime tel. no.:
Email address:
CHA R005
(Rev. 10/02)

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