State of North Carolina
Department of the Secretary of State
ARTICLES OF INCORPORATION NONPROFIT CORPORATION
COMMUNITY THIRD PARTY OR MEDICAID POOLED TRUST
55A-2-02 and §36D of the General Statutes of North Carolina, the undersigned corporation does hereby submit
these Articles of Incorporation for the purpose of forming a Community Third Party or Pooled Trust nonprofit corporation.
1. The name of the corporation is:_____________________________________________________________________________
2. _______ (Check only if applicable.) The corporation is a charitable or religious corporation as defined in NCGS
3. The street address and county of the initial registered office of the corporation is:
Number and Street_________________________________________________________________________________________
City, State, Zip Code___________________________________________________County______________________________
4. The mailing address if different from the street address of the initial registered office is:
5. The name of the initial registered agent is:
6. The name, address, and relationship to the Beneficiary of each board member/incorporator is as follows: __________________
7. (Check either a or b below.)
a.___The corporation will have members.
b.___The corporation will not have members.
8. Attached are provisions regarding the settlement of the corporation’s assets upon its dissolution.
9. Any other provisions which the corporation elects to include are attached.
10. The requirements of §36D-4 have been met.
11. Attached is a copy of the By-laws adopted by the Board in the manner prescribed by law.
12. The street address and county of the principal office of the corporation is:
13. The mailing address if different from the street address of the principal office is:
Revised July 2010
P. O. BOX 29622
RALEIGH, NC 27626-0622