Form 4720 - Return Of Certain Excise Taxes Under Chapters 41 And 42 Of The Internal Revenue Code - 2013 Page 10

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Form 4720 (2013)

Page

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my

knowledge and belief it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has

any knowledge.

Title

Signature of officer or trustee

Date

Signature (and organization or entity name if applicable) of manager, self-dealer, disqualified person, donor, donor

advisor, or related person

Sign

Here

Date

Signature (and organization or entity name if applicable) of manager, self-dealer, disqualified person, donor, donor

advisor, or related person

Date