Inser T Member Organization Name

INSERT MEMBER ORGANIZATION NAME

USE OF FUNDS AFFIDAVIT

1. I am a Director or employee of the above named Member Organization, and I am authorized to attest to our use of funds received from Authors Coalition of America LLC (the “Coalition”). To the best of my knowledge the information reported in this Use of Funds Affidavit is true and accurate.

2. During the 2013 calendar year, we used money received from the Coalition to fund or assist in the funding of the following projects or activities:

(List brief summary of activities funded with Coalition distributions.)

3. I verify that the above named Member Organization has acted in full compliance with the Coalition’s use of funds mandates.

DATED: ______

SIGNATURE: WITNESS:

______Sign on line, above Sign on line, above

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