State Form 10555 - Application For Registration Of A Professional Corporation - 2000 Page 2

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AFFIDAVIT OF SHAREHOLDER

A CORPORATION OF ACCOUNTING PROFESSIONALS

STATE OF INDIANA ____________________________

COUNTY OF__________________________________ SS:

being duly sworn, deposes

and says that he / she is a certified public accountant, public accountant or accounting practitioner (strike inapplicable designations) of the state

of Indiana, his / her office and principal place of business being located at

, Indiana, that

he / she is a shareholder of the corporation known as

that all statements made in this application regarding the said corporation are true; that said corporation has complied with all provisions of

corporation laws of this state applicable thereto; that each officer of said corporation is a certified public accountant, public accountant or accounting

practitioner in good standing of the state of Indiana; that each shareholder is a certified public accountant, public accountant or accounting

practitioner of Indiana in good standing; and each director is a qualified person as defined by IC 23-1.5-1-12.

Printed or typed name of applicant

Signature of applicant

Subscribed and sworn before me this

day of

Signature of Notary Public

Printed or typed name of Notary Public

SEAL

My commission expires

Residence county of Notary

Notary commissioned in State of: