Fill and Sign the Nonprofit Form 481378465

Proxy of Member of Nonprofit Corporation The undersigned, being a member of ____________________ (Name of Corporation), a ___________________ (name of state) nonprofit corporation, appoints _________________ (Name) , whose address is _______________________________________________________ _____________________________________ (street address, city, state, zip code), to be my lawful proxy to attend and represent me at any meeting of the Members of the corporation, and at any adjournment of a meeting, and to vote and act for me on any matter that may come before the meeting and take any other action which I could presumably take if present at the meeting. This proxy shall remain in effect for ____ months from the date of this proxy unless earlier revoked by me or replaced by substitution. Witness my signature this the _____ day of _____________, 20_____. ___________________________________ (Printed Name of Member)___________________________________ (Signature of Member) (Acknowledgment form may vary by state) State of _____________________ County of ___________________ Personally appeared before me, the undersigned authority in and for the said County and State, on this _______________ (date), within my jurisdiction, the within-named ______________________ (Name of Member) , who acknowledged that he executed the above and foregoing instrument. ________________________________ NOTARY PUBLIC My Commission Expires: ____________________