Applicant Organization’s Name:
Please complete either Section A or Section B, as appropriate for your circumstances.
Section A. Confirmation that signer of previously filed license application performs duties of treasurer or chief fiscal officer:
As the signer of the previously submitted license application and attachments, I affirm that although I do not possess the title
of “treasurer” or “chief fiscal officer” of the applicant organization, I perform the duties of the treasurer or chief fiscal officer
of the applicant organization, and that I acted in such capacity in preparing, signing, and filing the previously submitted
license application and attachments.
Signature:
Signer's Name (Print):
Signer's Title (Print):
Date:
Section B. Review and affirmation by applicant’s treasurer, chief fiscal officer, or person acting in such capacity.
I swear or affirm that I am, or perform the duties of, the treasurer or chief fiscal officer of the applicant organization, that I
reviewed the information in the license application and attachments previously filed under another signature, and that the
information furnished in this application and all supplemental forms, reports, documents, and attachments are true and correct
to the best of my knowledge under penalty of perjury.
Signature:
Signer's Name (Print):
Signer's Title (Print):
Notarization: The following is for a notary public to place you under oath and then notarize your signature:
(County)
(State)
County
and State in which acknowledgement taken
Sworn to and subscribed before me this the day of
in the year of .
Notary Public's Signature:
Notary Public's Name (Print):
Date Notary Public's Commission Expires:
If using a notary stamp or seal, stamp or imprint seal beside or below this line:
CSL Contact Information:
Agency Internet Site: www.sosnc.gov Electronic Mail: csl@sosnc.gov
Telephone: 919-814-5400 - Toll free for NC residents: 1-888-830-4989
Facsimile: (919) 807-2220
Mailing Address: P.O. Box 29622, Raleigh, NC 27626-0622
Signature Amendment Form
for charitable or sponsor organizations
Form Revision: September 24,2020
Effec
tive Date: June 7, 2005
Page 1 of 1
Signature Amendment Form
for charitable or sponsor organizations
North Carolina Department of the Secretary of State
Charitable Solicitation Licensing
