Division of Charitable Solicitations and Gaming
Office of Tennessee Secretary of State Tre Hargett
312 Rosa L. Parks Avenue, 8th Floor
Nashville, Tennessee 37243
615-741-2555
I certify that the information furnished in this summary and all supplemental forms, documents, and
continuation sheets is true and correct to the best of my knowledge and belief.
Signature of Authorized Officer:
Print Title (Mr., Mrs., etc.):
First:
MI:
Last:
Position Title:
Date:
Signature of Chief Fiscal Officer:
Print Title (Mr., Mrs., etc.):
First:
MI:
Last:
Position Title:
Date:
SS-6002 (Rev. 08/14), RDA 2994
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