Charitable Law Section Office 614.466.3181 Fax 614.466.9788 150 East Gay Street, 23rd Floor Columbus, Ohio 43215-3130 www.OhioAttorneyGeneral.gov NOTIFICATION FORM PROPOSED RELEASE OR MODIFICATION OF RESTRICTION UPON INSTITUTIONAL FUND PURSUANT TO OHIO REVISED CODE SECTION 1715.55(D) 1. State the name and principal place of business of the Institution giving notice under Revised Code Section 1715.55(D): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. State the name of the Institutional Fund subject to restriction and describe the charitable purpose for which it is held: ________________________________________________________________________ 3. If the Institution has delegated management and investment of the Institutional Fund to external agents, state the name and principal place of business of such agents: ________________________________________________________________________ 4. State the total value of assets of the Institutional Fund subject to restriction: $_____________________________ 5. State the date of inception of the Institutional Fund subject to restriction: ______________________________ 6. State the proposed effective date of the release or modification of the restriction: ______________________________ 7. Provide a copy of the gift instrument and indicate the specific restriction or restrictions for which release or modification is proposed: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 8. The Institution proposes that the restriction(s) detailed above be (select one): [ ] Released [ ] Modified Updated 2/11 American LegalNet, Inc. www.FormsWorkFlow.com 9. Explain the basis of the Institution's determination that the restriction contained in the gift instrument renders administration of the Institutional Fund unlawful, impracticable, impossible to achieve, or wasteful: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 10. If modification of the restriction is proposed, state the nature of the proposed modification and attach a copy of any document setting forth the restriction as modified: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 11. Explain how the Institution's use of the property is and will continue to be consistent with the charitable purposes expressed in the gift instrument: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ______________________________________________________ (Name of Institution providing notice) ______________________________________________________ (Signature of officer, director, or trustee of Institution) ______________________________________________________ (Name and title of officer, director, or trustee of Institution) Address: ______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Telephone Number: _____________________________________ Email Address: _________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com