Notice Of Establishment Of Catastrophic Illness Trust
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1State of Tennessee
NOTICE OF ESTABLISHMENT OF
CATASTROPHIC ILLNESS TRUST
Department of State
Division of Charitable Solicitations & Gaming
William R. Snodgrass Tennessee Tower
INSTRUCTIONS: Pursuant to T.C.A. § 35-11-111 et. seq., on the
th
312 Eighth Avenue North, 8
Floor
establishment of a catastrophic illness trust and prior to the
Nashville, TN 37243
solicitation of funds, the trustee shall file notice with the Secretary of
(615) 741-2555
FAX (615) 253-5173
State on this form.
PART A:
Name of Beneficiary
: ________________________________________________________________________________________
Physical Address
:
(Street)
(City)
(State)
(Zip)
Mailing Address
(if different):
(Street)
(City)
(State)
(Zip)
Telephone Number: (___)____________ Fax Number: (
)_____________ Email Address:_____________________
PART B:
Name of Trustee
: ____________________________________________________________________________________________
Physical Address
:
(Street)
(City)
(State)
(Zip)
Mailing Address
(if different):
(Street)
(City)
(State)
(Zip)
Telephone Number: (___)____________ Fax Number: (
)_____________ Email Address:_____________________
___________________________________________________________________________________
PART C:
Name of Financial Institution / Location of Assets
: ______________________________________________________________
____________________________________________________________________________________________________________
Physical Address
:
(Street)
(City)
(State)
(Zip)
Mailing Address
(if different):
(Street)
(City)
(State)
(Zip)
Contact Person
: _____________________________________________________________________________________________
Telephone Number: (___)____________ Fax Number: (
)_____________ Email Address:_____________________
___________________________________________________________________________________
PART D:
Methods of Fundraising:
1. __________________________________________________________________________________________________
2. __________________________________________________________________________________________________
3. __________________________________________________________________________________________________
___________________________________________________________________________________
SIGNATURE
I certify that the information furnished above (and all continuation sheets) is true and correct to the best of my
knowledge.
Notary Seal
Sworn to and subscribed before me (or to me personally known) at:
_________________________________________________
_____________________________________________________
Signature of Trustee
County / State
__________________________________________________
This, the _________ day of _____________________ 200______.
Print Name
Date
__________________________________________________
_____________________________________________________
Title
Signature of Notary
SS- 6073
6/26/07
RDA 1745
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