Free OFFICE OF THE SECRETARY OF STATE - Maryland

OFFICE OF THE SECRETARY OF STATE
CHARITIES AND LEGAL SERVICES DIVISION STATE HOUSE ANNAPOLIS, MD 21401 410-974-5534 http://www.marylandsos.gov

CERTIFICATION FORM
PLEASE COMPLETE THIS FORM AND SUBMIT IT WITH YOUR ORGANIZATION'S ANNUAL UPDATE OF INFORMATION Failure to sign and submit to the Charities and Legal Services Division the certification below will result in a delay of your organization's registration.

Name of Charitable Organization __________________________________________________________________ Address: _________________________________ City: __________________ State: ______ Zip Code: _________ Telephone Number: ________________________ Fax Number: _______________________________________

Does your organization engage or have a contract with a professional solicitor or fund-raising counsel? If yes, please attach a copy of the contract(s). In order to process your organization's application, you must respond to this question. Professional Solicitor Yes No Fund-raising Counsel Yes No

I hereby certify that this registration statement and all supporting documents are true to the best of my knowledge, and the IRS Form 990 or IRS Form 990-EZ for the fiscal year ending ___________ (month), ________ (year) submitted to the Office of the Secretary of State under §6-408 of the Business Regulation Article of the Annotated Code of Maryland is a copy of the form submitted to the Internal Revenue Service.

____________________________________ Name of Individual Preparing this Form

____________________________________ Signature

____________________________________ Title

____________________________________ Date