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Annual Report Of Board Member Of Hospital Or Medical Services Corp Form. This is a Tennessee form and can be use in Corporation Secretary Of State.
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Tags: Annual Report Of Board Member Of Hospital Or Medical Services Corp, SS-4497, Tennessee Secretary Of State, Corporation
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . Mail.or .deliver to:
... . . ..
Secretary of State
:
Corporate Filings
312 Eighth Avenue North
6th Floor, William R. Snodgrass Building
Nashville, TN 37243
Telephone Contact:
(615) 741-0537
Filing Fee: $20.00
Filing Deadline: January 10
Index No.
:
:
Plaintiff(s)
-against-
CONTROLNo.
Calendar NUMBER
JUDICIAL SUBPOENA
:
ANNUAL REPORT
OF A BOARD MEMBER OFA
:
HOSPITAL OR MEDICAL SERVICES CORPORATION
FILED PURSUANT TO TCA 56-29-105
:
TCA 56-29-105 requires each board member of a corporation organized and governed by Title 56, Chapter 29, to report to the
Defendant(s)
:
. . Secretary of. State: .(1). all compensation.received from the.corporation,. including payments for services actually rendered, (2)
........ .... . ............ ............ ........ .
any conflict of interest the director has due to service on the corporation's board; and (3) all income received from any
business interest that transacts business with or receives funds from a corporation organized and governed by Title 56,
Chapter 29. The report must be filed annually by January 10 and will be retained by the Secretary of State for three (3) years.
THE PEOPLE OFhospital or medical servicesYORK
THE STATE OF NEW corporation in which the undersigned serves as a board member:
1(a).
Name of
TO
1(b).
Name of board member (printed or typed):
2(a).
Compensation received as a board member of the corporation:
GREETINGS:
$
2(b).
Other payments received for services actually rendered to the corporation (such as and counsel, medical service,
WE COMMAND YOU, that all business and excuses being laid aside, you legal each of you attend before
accounting or other required service.)
,
the Honorable
at the
Court
County of SERVICES RENDERED located at
COMPENSATION
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
3.
Conflicts of interest due
result of your failure to comply. to service as a board member of the corporation.
Witness, Honorable
Court in
County,
4.
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
All income received from any corporation, partnership or other business interest that transacts business with or
receives funds from any hospital or medical services corporation governed by TCA 56-29-101 et.seq. listed by
source and amount.
SOURCE
Attorney(s) for
AMOUNT
Office and P.O. Address
Signature
SS-4497
Telephone No.:
Facsimile No.:
Date
E-Mail Address:
Mobile Tel. No.:
RDA Pending
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