Free Form - Tennessee

State of Tennessee

Department of State
Division of Charitable Solicitations & Gaming William R. Snodgrass Tennessee Tower 312 Eighth Avenue North, 8th Floor Nashville, TN 37243 (615) 741-2555 FAX (615) 253-5173

NOTICE OF ESTABLISHMENT OF CATASTROPHIC ILLNESS TRUST
INSTRUCTIONS: Pursuant to T.C.A. § 35-11-111 et. seq., on the establishment of a catastrophic illness trust and prior to the solicitation of funds, the trustee shall file notice with the Secretary of State on this form.

PART A:
Name of Beneficiary: ________________________________________________________________________________________ Physical Address: (Street) Mailing Address (if different): (Street)
(City) (City) (State) (State) (Zip) (Zip)

Telephone Number: (___)____________ Fax Number: (

)_____________ Email Address:_____________________

PART B:
Name of Trustee: ____________________________________________________________________________________________ Physical Address: (Street) Mailing Address (if different): (Street)
(City) (City) (State) (State) (Zip) (Zip)

Telephone Number: (___)____________ Fax Number: (

)_____________ Email Address:_____________________

___________________________________________________________________________________ PART C:
Name of Financial Institution / Location of Assets: ______________________________________________________________ ____________________________________________________________________________________________________________ Physical Address: (Street) Mailing Address (if different): (Street)
(City) (City) (State) (State) (Zip) (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

_________________________________________________ Signature of Trustee __________________________________________________ Print Name Date __________________________________________________ Title
SS- 6073 6/26/07

Sworn to and subscribed before me (or to me personally known) at: _____________________________________________________ County / State This, the _________ day of _____________________ 200______. _____________________________________________________ Signature of Notary
RDA 1745