CHARITABLE ANNUAL ESTIMATE OF CERTAIN REVENUE AND EXPENDITURESSECRETARY OF STATESFN 59569 (04-2014) Applicant's Signature DateDate TitleTitleInstructions:1. For reference see North Dakota Century Code Section 50-22-04.2. Please type or print, complete all blanks. Legal Name of OrganizationLegal Name of Organization Secretary of State ID NumberSecretary of State ID Number Street and Mailing Address of Principal OfficeStreet and Mailing Address of Principal Office CityCity StateState ZIP CodeZIP Code Federal ID NumberFederal ID NumberTherefore, I am asking for approval to provide a reasonable estimate for the required information.PERMISSION GRANTED ONLY AFTER SIGNED AND RETURNEDOffice of Secretary of State DateDate Secretary of StateName(s) Under Which the Organization Solicits ContributionsName(s) Under Which the Organization Solicits Contributions Telephone NumberI certify that I am unable to provide the total net amount disbursed or dedicated within North Dakota, broken down into total amounts disbursed or dedicated for each major purpose charitable or otherwise.I certify that I am unable to provide the funds or properties trI certify that I am unable to provide the funds or properties transferred out of state with an explanation as to recipient and purpose.FOR OFFICE USE ONLY ID NumberWO Number Issued By American LegalNet, Inc. www.FormsWorkFlow.com