Patriot Act Compliance Statement

Directions: Place this statement on your corporate letterhead. It must be signed by the head of the organization and dated within 90 days of the form submission.

The “ORGANIZATION NAME” does not directly or indirectly engage in or support any terrorist activity.  Neither the “ORGANIZATION NAME”, nor any officer or director of the “ORGANIZATION NAME”, is included on any lists of terrorists or terrorist organizations compiled by the United States government or any other national or international body, including but not limited to (i) the U.S. Treasury Department’s Specially Designated Nationals List,  (ii) the U.S. State Department’s Terrorist Exclusion List, (iii) the United Nations List Pursuant to Security Council Resolution 1390 (2002) and Paragraphs 4(B) of Resolution 1267 (1999) and 8(C) of Resolution 1333 (2000), and (iv) the European Union List Implementing Article 2(3) of Regulation (EC) No 2580/2001 on Specific Restrictive measures Directed Against Certain Persons and Entities with a View to Combating Terrorism.  The “ORGANIZATION NAME” does not distribute funds to benefit, directly or indirectly, any individual or organization that is engaged in or supportive of terrorism.

Signed:

__________________________________________    __________________________

Head of Organization                                                             Date