OFFICE OF THE SECRETARY OF STATE DECLINATION OF REMUNERATION BY ELECTED OR APPOINTED OFFICER 1. Print or type name, address, and phone number of the individual for which declinati on applies. Name ___________________________________________________________________ ___________________ Address ________________________________________________________________ ____________________ Phone Number (__________)_______________________ 2. Completeone of the following options: (a) I decline all remuneration associated with the office of ____________________________ ______________ (b) I decline the specific remuneration listed below for the office of ___________________________ ________ (Examples of specific types of remuneration include salary, compensatory per diem, reimbursement for expenses, longevr fityees pay.) , o________________________________________________________________________ _____________________________________ ________________________________________________________________________ _____________________________________ ________________________________________________________________________ _____________________________________ (Please note. The declination filed herein is effective on the date it is filed with the office of the Secretary of State. Additionally, adeclination filed after an officer has qualified for office may be revoked at any time. However, a declination filed before persa onhas qualified for office may not be revoked during the term of office to which the person is appointed or elected.) Signature of Officer Holder ___________________________________ Date ______ _______________________ State of _________________ County of ________________ Before me, a notary public, on this day personally appeared __________________________________, known to me to be the person whose name is subscribed to the foregoing document and, being duly sworn, declared that the statements therein contained are true and correct. Given under my hand and seal of office this _________ day of _______________________, _________. (seal) ________________________________ Notary Public Signature Form #2207 American LegalNet, Inc. www.USCourtForms.com