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Aftii:MRA&A"[~;~~• <br />Part C. Evidence of Nonprofit Organization <br />SECTION Z. LIST OF THE NONPROFIT ORGANIZATION'S BOARD MEMBERS, DIRECTORS AND OFFICERS <br />Name: <br />Home Address: <br />Title: <br />City: St.: Zip: Phone: ( ) Ext; <br />Occupation: Fax: ( ) <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity?'O ❑ Yes ❑ No <br />(2) have a relationship, as Affiliate or otherwise, w/ members of the Applicant or Development Team? " ❑ Yes ❑ No <br />Name: Title: <br />Home Address: <br />City: St.: Zip: Phone: ( ) Ext: <br />Occupation: Fax: ( ) <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity? ❑ Yes ❑ No <br />(2) have a relationship, as Affiliate or otherwise, w/ members of the Applicant or Development Team? ❑ Yes ❑ No. <br />Name: TiUe: <br />Home Address: <br />City: St.: Zip: Phone: ( ) Ext: <br />Occupation: Fax: ( ) <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity? ❑ Yes ❑ No <br />(2) have a relationship, as Affiliate or otherwise, w/ members of the Applicant or Development Team? ❑ Yes ❑ No <br />Name: Title: <br />Home Address: <br />City: St.: Zip: Phone: ( ) Ext: <br />Occupation: Fax: ( ) <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity? ❑ Yes ❑ No <br />(2) have a relationship, as Affiliate or otherwise, w/ members of the Applicant or Development Team? ❑ Yes ❑ No <br />Name: Title: <br />Home Address: <br />City: St.: Zip: Phone: ( ) Ext: <br />Occupation: Fax: ( ) <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity? ❑ Yes ❑ No <br />(2) have a relationship, as Affiliate or otherwise, w/ members of the Applicant or Development Team? ❑ Yes ❑ No <br />(Make additional copies of this form as required for additional board members, directors, and officers.) <br />10 An individual is considered to be acting in a private capacity if the individual is not an employee of a public body and <br />is not being paid by a public body while performing functions in connection with the nonprofit organization. A public <br />body is any state, city, county, town, township, village or other general purpose political subdivision of the stafe. <br />I I If "Yes" attach explanation of such relationship to this form. <br />Part II, Page 15 of 15 <br />