HomeMy WebLinkAbout2011 - Charitable Organization Registration ApplicationADAM H. PUTNAM 1 -800 -HELP -FLA (435-7352) • 850-488-2221 Calling Outside Florida a a assee,
COMMISSIONER www.800helpfla.com • 850410-3804 Fax
All documents and attachments submitted with this application are subject to public review pursuant to Chapter 119, F.S. PLEASE
TYPE OR PRINT. Additional pages may be attached if additional space is needed. All fees are non-refundable.
Business Information
New Application ❑ Renewal CH
Legal Name of Organ' tion/• /� / Q p� �/
o Lt 2 i - -3074 //JS M01) iii (ID6GLC�/(7 I eP Ix � ' -fz
Fictitious (DBA) Name:
'If you am a Fbrtda organieafion, all fictitious names must be mglstemd with the Division of OwporaOons. If business is a camorabon then 'Name' is the legal
name of the business as listed wdh the Division of Corporations.
Other Names Soliciting As:
E2 Street Address(wAsibAP T or SURE a in ss lines; addresses must match those Ned wtlh the 0ivivan ofCorponvws):
City: State: T
7—ice
Mailing Address (i/tlifierenf Imre above):
City:
ItTelephone Number:
%L) 23 !
Fax Number:
ZC--Z t I
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
CHARITABLE ORGANIZATIONS / SPONSORS
REGISTRATION APPLICATION
aableandremitke check or money order
payable
payable and remit with
application to:
" - Solicitations of Contributions Act
Chapter 496, Flonda Statutes
FDACS
SJ -7.004
P.O. Box 6700
T II h FL 32399$700
ADAM H. PUTNAM 1 -800 -HELP -FLA (435-7352) • 850-488-2221 Calling Outside Florida a a assee,
COMMISSIONER www.800helpfla.com • 850410-3804 Fax
All documents and attachments submitted with this application are subject to public review pursuant to Chapter 119, F.S. PLEASE
TYPE OR PRINT. Additional pages may be attached if additional space is needed. All fees are non-refundable.
Business Information
New Application ❑ Renewal CH
Legal Name of Organ' tion/• /� / Q p� �/
o Lt 2 i - -3074 //JS M01) iii (ID6GLC�/(7 I eP Ix � ' -fz
Fictitious (DBA) Name:
'If you am a Fbrtda organieafion, all fictitious names must be mglstemd with the Division of OwporaOons. If business is a camorabon then 'Name' is the legal
name of the business as listed wdh the Division of Corporations.
Other Names Soliciting As:
E2 Street Address(wAsibAP T or SURE a in ss lines; addresses must match those Ned wtlh the 0ivivan ofCorponvws):
City: State: T
7—ice
Mailing Address (i/tlifierenf Imre above):
City:
ItTelephone Number:
%L) 23 !
Fax Number:
ZC--Z t I
Email Address for Organization: Website:
c._1] Ragfstration Application Type: (496.404(1), 496.404(15), 496.404(21))
El Charitable ❑ Charitable/Parent ❑ Sponsor
FD Of organization: (496.405(2) (0, 496.409(2) (b), 496,410(2) (b), (c), F.S.)
Corporation ❑ LLC ❑IPPartnership ❑ Sole Proprietorship
❑ Other (please describe): _5V1 _ 3
De a incorpo ted or legally established: State:
%UI cC ��Ci'lrll�t
0 pay Vear
f6_'@ Federal Employer ID Number pig.o92, F.sp
DACS-10100 Rev. W/10
Page 1 of 8
State: Zip Code:
❑ Sponsor/Parent
Org Code: 42 10 06 12 000
E0: A2
Object Code: 001133 $10.00-$400.00
List all officers, directors, trustees, and principal salaried executive personnel: (495.405(2)(9)2, F.S./
(attach a separate sheet Hnecessary— you must provide physical address)
Name: Name: c
Title: A� /�C" f ,n 1,�//l' Title: � //� //[V
Address / /> /A/'/T�� J77tit-T�c Add /e��-s/J�4� //J'
City:/ I h4o / S _" Cit : 1 r �
Stated Zip Code: `� State:- Z1 Code:
l�-'�`- 3
Telephone Numbs Salaried? Telephone Number: Salaried?
(-Z) F> Yes O No ( ) - ❑ Yes Na
Name, Name:
/Lx)�C}� �
Title: i,�CLL V]'V1l1 71A Title:
Address:r Address:
l�ri-E 1I �
City: V 7/� (.Y� City:
State: L Zip Code: State: Zip Code: z l (,.
Telephone Number: Salaried? Telephone Number: Salaried?
( ) ❑ Yes 0 No ( ) - ❑ Yes ❑ No
j8a List all branch offices, chapters or affiliates located in the State of Florida. (attach a separate sheet if necessary)
Name: Name:
Title: Title:
Address: Address:
City: City:
State: Zip Code: State: Zip Code:
Telephone Number: Telephone Number:
Email: Email:
DAC&10100 Rev. 07110
Page 2 of 8
"bb If the charitable organization or sponsor does not maintain an office in Florida, provide the name, street address, and
telephone number of the person having custody of the financial records.
Name:
��hl2ti ��)r3Piy1 c
Address:
H, l0P&1-j) Kje4(LAy tf
Z:TelCity:
: Zip Code-
Telephone
ephone Number: Email:
S�3 Zy to CC6 IM
z - ��� he I c(9 LH Izr f f� r
Have any persons listed in question #7, oranyof its officers, directors, trustees, oremployees, persons with a controlling
interest in applicant, or agents involved in solicitation, regardless of adjudication, been convicted of, found guilty of, pled
guilty or nolo contendere to, or been incarcerated within the last 10 years as a result of having previously been convicted of,
or found guilty of, or pled guilty or nolo contendere to, any felony, or crime involving fraud, theft, larceny, embezzlement,
fraudulent conversion, misappropriation of property, or any crime arising from the conduct of a solicitation for a charitable
organization or sponsor within the last 10 years? i496.4o5(z)(a)5, fis.)
❑ Yes ff No If yes, please provide the following information for each individual: (attach a separate sheet if necessary)
Title: I� I
Name:
Nature of offense:
Court having jurisdiction:
Disposition of offense:
Date:
I I
vwun oy rev
Date:
.woom I oer I roar
0 Have any persons listed in question #7, orany of its officers, directors, trustees, or employees, persons with a controlling
Interest in applicant, or agents involved in solicitation, been enjoined from violating any law relating to a charitable
solicitatlo (496.405(1)(e)6, F.S.)
❑ Yes No If yes, please provide the following information for each individual: (attach a separate sheet if necessary)
Name:
Court issuing the injunction:
Date of injunction:
vv4n oq rev
Ust name of person(s) from question #7 ponsible for solicitation or fundre(sing activities: /49s.4os(y(y. FS/
rN'��2y 1���)v��
BE List the name, address, and telephone number(s) of pamon(s) from question #7 responsible for the custody and final
distribution of contributions: f4gs.4o5p)(9)s, Fs.)
Name: Address: Telephone Number:
Name: Address: Telephone Number:
Name:
nACS10100 Rev. %/10
Page 3 of 8
Address:
Telephone Number:
w .sunbiz.org - Department of State page i of i
Annual Report Online Filing
Document Number N07000011988
L'
Thank you for filing your Annual Report online. Your report fled date will be today's date if there are no processing errors. ,
Your confirmation number is 400218796444.
Your charge amount is $61.25.
httns://fis.sunhi7..org/scrintg/ubrrfs.exe 1 n RM t a
M Month/Day fiscal year ends: f496.4o5(2]Ig)3, Fs:] I
samn oar
EM Has organization been granted tax exempt status by the Internal Revenue Service? [496.405(2)(0, F.S.]
es 501(c) (C)IW-yes, you must attach a copy of the fizz exemption determination letter from the IRS.
()nse2number)
❑ Pen ng (fat exemp54n determinatton ledermusf be subm&ed with mnewa9
So What is the p rposo which the organization is organized 96.4a5(2)(b)' F.S.] '
/ !»%a� n r�culs�PuP y oar
o ) .fa.` I�/nJ(�WL�C'
fI, tUr
¢-kn —
IfflWhatisthe purpose forwhichIe co�ntrila tions will be used? 1496.40(2Xb), Fs:]
I NF1 PAsa � ZOI -
List ma or program activities: (496.405(2)(9)4, F.S.]
DlLChcDiU/ (2, 7L` ff� F4T70O; �l �f/CIC��TSF?2 liQC7 t���(�J
r u ,
_18. Is this charitable organizationisponsor authorized by any other state to solicit contributions? 1496.405(2)(d)t, F.S.]
❑ Yes BNo
19. Has the charitable organization/sponsor or any of its officers, directors, trustees, or principal salaried executive
personnel been enjoined in any jurisdiction from soliciting contributions or been found to have engaged in
unlawful tactless in the solicitation of contributions or administration of charitable assets? (496.405(2)(d)2. F.S.]
[I Yes No
20.( Has the charitable organizationlsponsor had its registration or authority denied, suspended, or revoked by any
governor tal agency? [496.so5(2)(d)3, Fs.]
❑ Yes No If yes, please explain the reasons for the denial, suspension or revocation:
JYJA Has the charitable organizationisponsor voluntarily entered into an assurance of voluntary compliance (AVC)
or agreee ent similar to that set forth in s.496.420, Florida Statutes? (496.4o5p)(d)4, Fs.]
❑ Yes f9 No If yes, attach a copy of the agreement.
Does the haritable organization or sponsor employ a professional solicitor? (496.4osp)(e). Fs.]
❑ Yes No If yes, attach a copy of the current contract, and provide the following information for each.
(attach a separate sheet IFnecessaty)
Name:
Address:
City:
Telephone Number:
f )
DAcsmtOo Rev.07110
Page 4 of 8
State:
Florida Registration Number.
ss-
Zip Code:
Dates of contract:
Beginning Date:_ I I
/Moto OeY vwr
bmu -(n om
End Date: I I
/MMI, wY vwr
JON Does th($ charitable organization or sponsor employ a professional fundraising consultant? (496.405(2)(e), F.S.)
❑ Yes L'J No (attach a separate sheet It necessary)
Name:
Address:
City:
Telephone Number:
1 ) -
Dates of contract:
Beginning Date: I /
Arron ay vx.
State: Zip Code:
Florida Registration Number:
FC -
End Date: I I
w u oar vxr
Indicate the type of financial report you are filing for the immediately preceding fiscal year: 1496.4o5(2)(s), F.S.)
❑ Budget (new organizations only)
12r Department's financial report form - See pages 7 and 8
❑ 990 with Schedule A - See item #25 of instructions for completing the Financial Report
❑ 990 -EZ - See item #25 of Instructions for completing the Financial Report
❑ 990 -PF - See item #25 of instructions for completing the Financial Report
ONLY SPONSORS. NEED TO ANSWER THE FOLLOWING QUESTIONS:
(25. _ If a sponsor, answer the following: (496.426, F.S.)
a. Does the organization consist of members who are individuals of whom at least 10% or 100 members, whichever is less,
are actively employed as law enforcement officers or emergency service employees by an agency of the United States,
this state, a municipality, or a political subdivision of this state, and who personally sign written membership agreements
with the organization and pay an annual membership of not less than $10 a member?
❑ Yes ❑ No
b. Total number of sponsor's members:
c. Total number of members actively employed as law enforcement or emergency service employees:
d. Percentage of total net contributions, which are dispersed in the stale on behalf of its members in furtherance of its stated
purposes or programs (defined as the total amount of all contributions raised minus the total cost of expenses incurred in
raising contributions solicited):
%
CONTACT PERSON
28�Person responsible for completing this application:
Nam TAIAph=mIaeb Email:
DACS-10100 Rev.07I10
Page S of B
ro U //I c.
(Organkiffon ame) 3/
FINANCIAL STATEMENT OF SUPPORT/REVENUE AND EXPENSES FOR FISCAL YEAR ENDING
NOTE: In lieu of oomplefing the following financial stalemenl, you may send the IRS 990 with Schedule A, 990-F2 or 990 -PF.
Is this a consolidated financial statement? 13Yes ONo
REVENUE
1. Contributions, gifts, grants, and similar amounts received
a. Direct public support (attach list of charitable organizations or sponsors,
professional solicitors, fundralsing consultants and commercial co -
venturers used, if any, and the amounts received from each of them, If
any. (495.407(1)(c), F.S.))
b. Indirect public support (attach list of sources and amounts)
c. Grants (attach list of sources and amounts)
d. Total (add lines la, ib, and 1c)
2. Inventory sales
a. Gross sales
b. Less cost of goods sold
c- Gross profit (or loss) (line 2a less line 2b)
3. Special events and fundraising activities
a. Gross revenue (not Including contributions reported on line 1)
b. Less direct expenses
c. Net income (or loss) (line 3a less line 3b)
4. Program service revenue
5. Membership dues and assessments
S. Sale of assets other than inventory
a. Gross sales
b. Less sales expenses
c. Net gain (or loss) (line 6a less line 6b)
7. In-kfnd contributions and services
8. Other revenue (attach list of sources and amounts)
9. TOTAL REVENUE (add lines 1d, 2c, 3c, 4, 5, 6c, 7, and 8)
EXPENSES
10. Program services (including payments to affiliates)
11. Management and general
12. Fundraising
13. TOTAL EXPENSES (add lines 10, 11, and 12)
NET ASSETS
14. Excess (or defielt) for the year (line 9less line 13)
15. Net assets or fund balance at beginning of year
16. Net assets or fund balance at end of year (add lines 14 and 15)
Balance Sheet:
Cash, savings and investments
Land and building
Other assets (describe on separate sheet)
Total assets
Total liabilities (describe on separate sheet)
Total assets or fund balance
DACS-10100 Rev. 07110
Page 6 of 8
la
ib.
to.
2a.
2b.
3a.
3b.
Be.
6b.
td
20
3c.
4.
5
6c.
7.
S.
9.
10.
11.
12.
13.
14.
15.
16.
(A) Be9hnin9 Qr. �S (B%fr df. 6
14:vzus
ri CJ
(Line 15)���Line 16)
(A) Total (sum of B, C, D) I (B) Program Services I (C) Management and General I (D) Fundraising
and Allocations llf
non-cashi�
schedule) r' `
Assistance to individuals
(attach schedule)
Benefits to members
(attach schedule)
Compensation to officers, etc.
(Other salaries, wages, etc.
(Other benefits, pensions, etc.
Payroll taxes
Professional fundraising fees
(Accounting fees
Legal fees
Supplies
(Telephone
Postage and shipping
Equipment rental
Occupancy
Printing
ITravel
IConferences and meetings
IInterest
Insurance
Other(describe)
Other (describe)
IOther (describe)
Other (describe)
Total Expenses
DACS10100 Rev. 0]110
Page 7 of 8
State of: I' in , ri rk
County of: 1 1j1 \ 1 A K1 12 \der
1. `v/ice
1 am the etil
i Title
and further state that:
Oa43416
having first made due oath or affirmation, say that
of T7'V/1.�✓Lf�
6 Name ofOifjanizationorCompany J,tt
1. LA RQ \ I W A p �1 1 C kC -.ompleted the Registration Statement;
Name of person otimplating registration if different from above
2. The Registration Statement is made for the purpose of complying with the provisions of Chapter 496, Florida
Statutes, Solicitation of Contributions Act;
3. 1 have read the Registration Statement
taand
dkknow the corftenqfteeo
Signature
Sworn to (or affirmed) and subscribed before me this [ 4 day of NOtmMhpr , a 01 I
by LA-,rr J U\.kiptj,c , who is personally known to me or who has produced
V, h L as identification.
SEALISTAMP I �, C11:N. DELDSq
€%IN, MYCOMMf6SI0N OpD]96266I
WLL�S7 EXPIRES: JUN 16.2012
"� 9ann1lrtmu0A In SNb Mwanre
DACS.10188 Rev. W/10
Page 8 of 8
(,P, � , - - � - -i: �' f,'. .
Notary Public Signature
�iOrtnlc�i �I.wC`
Notary Pubic Name, Please Pdnt
RBC Bank"'
FOUR CHAPLAINS MONUMENT, IRC, INC.
101 ISLAND SANCTUARY
VERO BEACH, FL 32963-3907
BANK USE
00000
T MS
D=0001
C=0001
12/31/11
ACCT# -
December 1, 2011 -jaffiojjffj�Page 1 of 1
________________________________ ___-_____-----------------------------
Please be advised that paper U.S. Savings Bonds will no longer be sold through
financial institutions or via mail order after December 31, 2011. In preparation for
this change, RBC Bank will stop selling savings bonds at 2:OOpm on Friday, December
30th. After this date, you can buy and manage electronic savings bonds online through
TreasuryDirect at www. treasurydirect.gov. If you have any questions regarding this
change, please contact your local banking center or visit the TreasuryDirect site.
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking
Beginning Balance
Additions +
Reductions -
Ending Balance
Checking Deposits
Detail 12/20 Deposit
4
$ 18,597.40
100.00
Amount
$ 100.00
Checks
Number
Reference
Amount Date
Number Reference Amount Date
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
2511
9950086611
1,275.00 12/05
Checking
Date
Balance
Date
Balance Date Balance
Balance
xxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxx
History
12/05
$ 17,322.40
12/20
17,422.40
r
RBC Bank,..
FOUR CHAPLAINS MONUMENT, SRC, INC.
102 ROYAL OAK DRIVE APT 106
VERO BEACH, FL 32962-3015
BANK USE
00000
T MS
D=0001
C=0000
11/30/11
ACCT# -
November 1, 2011 --1 Page 1 of 1
------------------------------------------- ______-_-_-------------------_
For account inquiries, please call 1 -877 -RBC BANK (722-2265) or log into Online
Banking at wwwrbcbank. com
----------------------------------------------------------------------------------------------
checking
Summary Business 150 Checking #
Beginning Balance $ 18,607.40
Additions + .00
Reductions - 10.00
Ending Balance
----------------------------------------------------------
Checks
Checking Number Reference Amount Date Number Reference Amount Date
Detail xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
2510 9950122422 10.00 11/21
Checking Date Balance Date Balance Date Balance
Balance xxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxx.
History 11/21 $ 18,597.40
RBC Bank'"
FOUR CHAPLAINS MONUMENT, INC, INC.
102 ROYAL OAK DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
TME
D=0001
C=0003
10/31/11
ACCT# -
October 1, 2011 - Page 1 of 1
---------------------------------------------------------------------------------------------
For account inquiries, please call 1 -877 -RBC BANK (722-2265) or log into Online
Banking at w .rbcbank.com
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking
Beginning Balance
Additions +
Reductions -
Ending Balance
Checking Deposits
Detail 10/04 Deposit
10/21 Deposit
10/28 Deposit
#
$ 17,136.28
1,856.12
385.00
Amount
$ 1,786.12
50.00
20.00
Checks
Number Reference Amount Date Number Reference Amount Date
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
9950085547 385.00 10/31
Checking
Date
Balance
Date
Balance Date Balance
Balance
xxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxx
History
10/04
$ 18,922.40
10/28
18,992.40
10/21
18,972.40
10/31
18,607.40
�V RBC Bank"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106
VERO BEACH, FL 32962-3015
BANK USE
00000
T MS
D=0000
C=0000
9/30/11
ACCT# -
September 1, 2011 - 6Mtmbe� Page 1 0£ 1
____________________ _____
For account inquiries, please call 1 -877 -RBC BANK (722-2265) or log into Online
Banking at w .rbcbank.com
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking #
Beginning Balance $ 17,136.28
Additions + .00
Reductions -.00
Ending Balance
RBC Bank"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T MS
D=0001
C=0000
8/31/11
ACCT# -
August 1, 2011 - 1 Page 1 of 1
_------ ____---- _______________
For account inquiries, please call 1 -877 -RBC BANK (722-2265) or log into Online
Banking at w .rbcbank.com
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking
Beginning Balance
dd tions +
End a.Ce
#
$ 32,136.28
.00
----------------------------------------------------------
Amount Date Number Reference Amount Date
KXXXXXXXXXXXXXXXX xXxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
15,000.00 8/26
Date Balance Date Balance
xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
RBC Bank"
FOUR CHAPLAINS MONUMENT, IAC, INC.
102 ROYAL OAK DRIVE APT 106
VERO BEACH, FL 32962-3015
BANK USE
00000
T MS
D=0000
C=0000
7/31/11
ACCT# -
Su 1y 1, 2011-Wgr$1:;2031 Page 1 of 1
At RBC Bank, we strive to offer the highest level of service and access for our
clients. Because of this, we have recently made changes to our next -day funds
availability policy to provide you with greater access to funds the day after
depositing a check with us. Now, when certain holds are placed on a deposited check,
the amount of funds available for withdrawal on the next business day is $200
(increased from $100), provided the check exceeds that amount. We hope you will find
this new policy allows greater flexibility and convenience to meet your daily banking
needs. If you have any questions regarding this change, please contact your local RBC
Bank.
Checking
Summary Business 150 Checking
Beginning Balance
Additions +
Reductions -
Ending Balance
#
$ 32,136.28
.00
_0
8
BC Bank"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T MS
D=0001
C=0002
6/30/11
ACCT# -
June 1, 2011 - Amww&NW1 Page 1 of 1
----------------------------------------------------------------------------------------------
For account inquiries, please call 1 -877 -RBC BANK (722-2265) or log into Online
Banking at w .rbcbank.com
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking #
Beginning Balance $ 34,596.28
Additions + 540.00
Reductions
Ending Balance
- --------------------------------------------------------
Checking Deposits Amount
Detail 6/06 Deposit $ 500.00
6/27 Deposit 40.00
Checks
Number Reference Amount Date Number Reference Amount Date
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
9950364328 3,000.00 6/14
Checking Date Balance Date Balance Date Balance
Balance xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
History 6/06 $ 35,096.28 6/14 32,096.28 6/27 32,136.28
RBC Bank"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106
VERO BEACH, FL 32962-3015
BANK USE
00000
T MS
D=0000
C=0001
5/31/11
ACCT# -
May 1, 2011 -,May 31, 2011 Page 1 of 1
-------------- yo-= _-__ _-_-___-__-____------------_---------_-
Ur ent Notice: Beginning ng MMa 31, 2011, an checks, drafts or de
g g g y y posits will be
returned unpaid if they contain a routing number and/or account number from a bank
that previously merged with RBC Bank (The Peachtree Bank, Indian River National Bank,
Cypress Coquina Bank, Millennium Bank, Georgia State Bank, Florida Choice Bank,
Community Bank of Naples, N.A., Alabama Exchange Bank, First American Bank and First
Gulf Bank). If you are still using such items from these banks, please contact your
banking center or call 1 -877 -RBC BANK immediately to order new checks and/or deposit
tickets. You must begin using the new items right away to ensure any outstanding
items clear prior to May 31. We are ready to assist you, and the process takes no
more than 10 minutes.
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking
Beginning Balance
Additions +
Reductions -
Ending Balance
Checking Deposits
Detail 5/16 Deposit
#
$ 34,586.28
10.00
00
IMMIEW
Checking Date Balance Date Balance
Balancexxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
History 5/16 $ 34,596.28
Amount
$ 10.00
Date Balance
xxxxxxxxxxxxxxxxxxxxxxx
RBC Bank'"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106
VERO BEACH, FL 32962-3015
BANK USE
00000
T MS
D=0000
C=0001
4/30/11
ACCT# -
April 1, 2011 -MMOMMOMM Page 1 of 1
Thank you for choosing RBC Bank for your financial needs. Please be advised that RBC
Bank allows you to make Non -Visa Debit Transactions through our STAR & Cirrus
network affiliations. These types of transactions include, but are not limited to,
bill payments made at a merchant's website or other Internet -based transactions. You
may be asked to enter your PIN while making these transactions or authenticate
yourself as the cardholder through any other way established by the merchant's
website. Certain provisions, such as the Visa zero -liability program, do not apply
to these Non -Visa Debit Transactions. If you have questions, please visit your
local banking center or call our Client Service Department at
1 -877 -RBC BANK (722-2265)
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking #
Beginning Balance
Additions +
Reductions -
Ending Balance
$ 34,286.28
300.00
INMEMPEMW
Checking Deposits
Detail 4/05 Deposit
Checking Date Balance
Balance xxxxxxxxxxxxxxxxxxxxxxx
History 4/05 $ 34,586.28
Date
Interest Paid During
Tax Year 2010
$ .30
Amount
$ 300.00
Balance Date Balance
RBC Bank"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106
VERO BEACH, FL 32962-3015
BANK USE
00000
TMS
D=0001
C=0002
3/31/11
ACCT# -
March 1, 2011 - �""'' 7011 Page 1 of 1
Refer a Friend to the better banking you experience today] With RBC Bank, your
friends, family and colleagues can simplify their finances with our convenient and
flexible account solutions; and also enjoy personal service and knowledgeable advice
in a relationship where the client always comes first. Plus you'll both get $251 To
get started, stop by your nearest RBC Bank location or visit rbcbankusa.com/refer
and complete a referral coupon.
Program restrictions and eligibility requirements apply. See your RBC Bank
representative for details.
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking
Beginning Balance
Additions +
Reductions -
Ending Balance
Checking Deposits
Detail 3/09 Deposit
3/29 Deposit
#
$ 35,234.88
125.00
1,073.60 Interest Paid During
NOUN Tax Year 2010 $ .30
------------------------------------------------------------
Checks
Number Reference
xxxxxxxxxxxxxxxxxxxxxxx:
2509 9950106244
Checking Date Balance
Balance xxxxxxxxxxxxxxxxxxxxxxx
History 3/09 $ 35,259.88
Amount
$ 25.00
100.00
Amount Date
Number
Reference
Amount Date
xxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
1,073.60 3/16
Date
Balance
Date
Balance
xxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxx
3/16
34,186.28
3/29
34,286.28
RBC Bank`"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106
VERO BEACH, FL 32962-3015.
BANK USE
00000
T MS
D=0000
C=0003
2/28/11
ACCT# -
February 1, 2011 - 9WEENdw011 Page 1 of 1
---------------------"""-'__-----------------------------
For account inquiries, please call 1-800-236-8872 or log in to Web Banking at
www. rbcbankusa.com.
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking
Beginning Balance
Additions +
Reductions -
Ending Balance
Checking Deposits
Detail 2/01 Deposit
2/01 Deposit
2/07 Deposit
#
$ 32,985.88
2,249.00
00 Interest Paid During
on Tax Year 2010
Checking Date Balance Date Balance
Balance xxxxxxxxxxxxxxxxxxXXXXX XXXXXXXX%%X%XX%XXXXXXXX
History 2/01 $ 33,135.88 2/07 35,234.88
$ .30
Amount
$ 100.00
50.00
2,099.00
Date Balance
RBC Bank'"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106
VERO BEACH, FL 32962-3015
BANK USE
00000
T MS
D=0001
C=0003
1/31/11
ACCT# -
January 1, 2011Page
Page 1 of 1
_-______1__201_____------------------------------------------------------------
For account inquiries, please call 1-800-236-8872 or log in to Web Banking at
www. rbcbankusa.com.
______________________________________________________________________________________________
checking
Summary Business 150 Checking p
Beginning Balance $ 16,918.08
Add#% YY + 16,230.00
Reductions - 162.20 Interest Paid During
Ending Balance Tax Year 2010 $ .30
Checking Deposits
Detail 1/18 Deposit
1/18 Deposit
1/21 Deposit
Amount
$ 16,000.00
50.00
180.00
Checks
Number Reference Amount Date Number Reference Amount Date
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
2508 2210215247 162.20 1/28
Checking Date Balance Date Balance Date Balance
Balance xxxxxxxxxxxxxxxxxxxxxxx XXXxXXXxxxxxxxxxxxXXXxx xxxxxxxxxxxxxxxxxxxxxxx
History 1/18 $ 32,968.08 1/21 33,148.08 1/28 32,985.88
RBC BanIC
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T ME
0=0000
C=9005
12/31/10
ACCT11 -
December 1, 2010 - Page 1 of 1
______________________________
_________________________________________________ --
For account inquiries, please call 1-800-236-8872 or log in cc Web Banking at
www.rbebackusa,com.
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking k
Beginning Balance $ 16,423.08
Additions + 495.00 Interest Paid Year -To -Date .30
Reductions 00
Ending Balance
__________________________________________________________________________________
Checking Deposits
Detail
12/03
Deposit
12/13
Deposit
12/21
Deposit
12/21
Deposit
12/28
Deposit
Checking
Date
Balance
Balance
xxxxxxxxxxxxxxxxxxxxxxx
History
12/03
$ 16,673.08
12/13
16,773.08
Date Balance
xxxxxxxxxxxxxxxxxxxxxxx
12/21 16.89B.09
12/28 16.918.08
Amount
5 250.00
100.00
100.00
25.00
20.00
Date Balance
RBC Bank"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAR DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T ME
O"0000
C-0005
11/30/10
ACCIB -
November 1, 2010- �--------------------------------------------page 1 of 1
_
-------- ____---- ______________-__-___
For account inquiries, please call 1-800-236-8872 or log in to Web Banking at
www. rbcbaBkusa....
______________________________________________________________________________________________
Checking
Summary Business 150 Checking N
Beginning Balance $ 14,498.08
Additions 1,925.00 Interest Paid Year -'1'o -Date .30
Reductions
Ending Balance
Checking
Deposits
Amount
Detail
11/15 Deposit
$ 1,485.00
11/16 Deposit
115.00
11/17 Deposit
225.00
11/17 Deposit
50.00
11/26 Deposit
50.00
Checking
Date Balance
Date
Balance
Date Balance
Balance
xxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxkxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxx
History
11/15 $ 15,983.08
11/17
16,373.08
11/16 16,098.08
11/26
16,423.08
RBC Bank'°
FOUR CHAPLAINS MONUMENT, IRC, INC
102 ROYAL OAR DRIVE APT 106 DANK HER
V£RO BEACH, FL 32962-3015 00000
P MS
D-0000
C=0001
10/31/10
ACCTA -
October 1, 2010 - October 31, 2010 Page 1 of 1
---------------------------------------------------------------------------------------------
For account inquiries, please call 1-800-236-8892 or log in to Web Banking at
www. Ibcbank.sa.c.a.
----------------------------------------------------------------------------'-------------'
Checking
Summary Business 150 Checking N
Beginning Balance $ 14,448.08
Additions + 50.00 Interest Paid Year -To -Date 30
Reductions - .00
Ending Balance I
----------------------------------------------------------------------------------
Checking Deposits Amount
Detail 10/08 Deposit $ 50.00
Checking Data Balance Date Balance Date Balance
Balancexxxxxxxxxxxxx xxx xxxxxxxxxxxxxxxxxxxxxxx xxxxzzxxxxzxzzxxxxzzxxx
zxxxxxx
History 10/08 $ 14,498.08
RBC Bank('
FOUR CHAPLAINS MONUMENT, INC, INC.
102 ROYAL OAK DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T ME
D-0000
0.0002
9/30/10
ACCT11 -
September 1, 2010 - Page i of 1
_________________________________________________________________ _______
Transactions that are restricted under the Unlawful Internet Gambling enforcement Act
are prohibited by law and shall not be processed through your Account.
______________________________________________________________________________________________
Checking
Summary Business 150 Checking N
Beginning Balance 5 14,388.08
Additions + 60.00 Interest Paid Year -TO -Date .30
Reductions .00
Ending Balance
Checking
Deposits
Amount
Detail
9/07 Deposit
5 10.00
9/16 Deposit
50.00
Checking
Date Balance
Date Balance
nate Balance
Balancexxx
xxzzxxx xxxxxxxxxxxxx
xxxxx
xxxzxxx xxxxxzxzx xx
xxxxxxzxxxxxzxxxxxxxxxx
History
9/07 6 14,398.08
9/16 14,448.08
RBC Bank'
POUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T MS
D-0000
C=0004
8/31/10
ACCT# -
August 1, 2010 - A Page 1 of 1
-------------------------------__-------------------------_--------------_
For account inquiries, please call 1-800-236-8872 or log in to Web Banking at
ww.rbcbankusa.com.
----------------------------------------------------------------------------------------------
Checking
Summary Bualneas 150 Checking it
Beginning Balance $ 13,888.08
Additions + 500.00 Interest Paid Year -To -Date .30
Reductions
Balanc.00e
Reding lance
Checking Deposits
Detail
8/02
Deposit
8/03
Deposit
8/16
Deposit
8/20
Deposit
Checking
Date
Balance
Balancexxx
x8/02x% x%$•13,938.08
History
8/03
14,288.08
Date Balance
xxxxxxxxxxxxxxxxxx
x8/18 14,338.08
8/20 14,388.08
Amount
S 50.00
350.00
50.00
50.00
Date Balance
WIN RBC Bank"
LNKH
FOUR CHAPLAINS MONUMENT, IRC, INC
102 ROYAL OAK DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T MS
D-0000
C=0001
7/31/10
ACCTN -
July 1, 2010 - �1, 2010 page 1 of 1
At RBC Bank, our most important goal in serving your financial needs is to help you
eat. a better today and a more secure tomorrow. whether that's finding more
convenient ways to manage your daily finances, establishing a savings plan,
purchasing a home or making your budget go further, we're committed to delivering
practical advice and relevant banking solutions that give you the confidence to
create your path forward. we invite you to stop by your local banking center to meet
with one of our experienced bankers to discuss your everyday needs and future goals.
Compare those needs to the solutions you're using today and identify ways to better
match the way you bank with the way you live and work. To find the location nearest
you, visit wwwrbcbankusa.hom or call 000-236-8872.
Checking
Summary Business 150 Checking 0
Beginning Balance $ 13,838.08
Additions. ♦ 50.00 Interest Paid Year -To -Date .30
Reductions - 5� .00
Ending Balance
-------------------------------------"----------------------------""----------
Checking Deposits Amount
Detail 7/21 Deposit $ 50.00
Checking Date Balance Date Balance Date Balance
Balance%%%% %%%%X%X.X%%X.%%%X.%%X%%XX% %%.%%%.%XXXXXXXX%%%%XXX.X%
History X7/21XX $ 13,688.08
RBC Bank"
FOUR CHAPLAINS MONUMENT, IRC, INC
102 ROYAL OAK DRIVE An 106 BANK USE.
VERO BEACH, FL 32962-3015 00000
T MS
D-0000
C-0000
6/30/10
ACCTS -
June 1, 2010 -0 Page 1 of 1
At RBC Bank, our most important goal in serving your financial needs is to help you
create a better today and a more secure tomorrow. Whether that's finding more
convenient ways to manage your daily finances, establishing a savings plan,
purchasing a home or making your budget go further, we're committed to delivering
practical advice and relevant banking solutions that give you the confidence to
create your path forward. we invite you to stop by your local banking center to meet
with one of our experienced bankers to discuss your everyday needs and future goals.
Compare those needs to the solutions you're using today and identify ways to better
match the way you bank with the way you live and work. To find the location nearest
you, visit www.rbcbankusa.com or call 000-236-6872.
----------------------------------------------------------------------------------------------
Checking
summary eusiness 150 checking 8
Beginning Balance $ 13,838.08
Addition. t .00 Interest Paid Year -To -Date .30
Reductions - .00
Ending Balance
�m
RBC BankW'
FOUR CHAPLAINS M0NUMEc17, IAC, INC.
102 ROYAL OAK DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T MB
D-0000
C.0000
5/31/10
ACCT11 -
May 1, 2010 - 10 Page i of 1
__________________________________________________________.___________
At RBC Bank, our most important goal in serving
ng your financial needs is to help you
create a better today and a more secure tomorrow. Whether that's finding more
convenient ways to manage your daily finances, establishing a savings plan,
purchasing a home or making your budget go further, we're committed to delivering
practical advice and relevant banking solutions that give you the confidence to
create your path forward. we invite you to stop by your local banking center to meet
with one Of our experienced bankers to discuss your everyday needs and future goals.
Compare those needs to the solutions you're using today and identify ways to better
match the way you bank with the way you live and work. '1'o find the location nearest
you, visit wwwrbcbankusa.com or call 800-236-8872.
Checking
Summary Business 150 Checking 9
Beginning Balance $ 13,838.08
Additions ♦ .00 Interest Paid Year -TO -Date .30
Reductions .00
Ending Balance
�V
RBC Bank'"
FOUR CHAPLAINS MONUMENT, INC. INC.
102 ROYAL OAR DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T ME
D-0000
C-0002
9/30/10
ACCTN -
April 1, 2010 - Page 1 of 1
Thank you for choosing RBC Bank for your financial needs. Please be advised that
RBC Bank allows you to make Non -Visa Debit Transactions through our STAR 6 Cirrus
network affiliations. These types of transactions include, but are not limited to,
bill payments made at a merchant's website or other Internet -based transactions. You
may be asked to enter your PIN while making these transactions or authenticate
yourself as the cardholder through any other way established by the merchant's
website. Certain provisions, such as the Visa zero -liability program, do not apply
to these Non -Visa Debit Transactions. If you have questions, please visit your
local banking center or call our Client Service Department at 1-800-236-8872.
----------------------------------------------------------------------------------------------
Checking
Summary Business 150 Checking ff
Beginning Balance $
13,733.08
Additions a
105.00
Interest Paid Year -To -Date
.30
Reductions -
00
Interest Paid During
Ending Balance awdavalft
Tax Year 2009
$ 3.25
Checking
----------------------------------------------------------------------------------
Deposits
Amount
Detail
4/15 Deposit
$ 50.00
4/16 Deposit
55.00
Checking
Date Balance
Date
Balance Date
Balance
Balancexxzxxx
xx$x
xxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxx
History
4/1513(783.08
4/16
13,838.08
�o
RBC BankW'
FOUR CHAPLAINS MONUMENT, INC, INC.
102 ROYAL OAK DRIVE APT 106 BANK USE
VERO BEACH, FL 32962-3015 00000
T ME
D=0001
C=0004
3/31/10
ACCT# -
March 1, 2010 -6001,010 Page 1 of 1
----------------------------------- ----------------------------------------------------------
For account inquiries, please call 1-800-236-8872 or log in to Web Banking at
www. rbcbankusa.com.
______________________________________________________________________________________________
Checking
Summary Business 150 Checking 0
Beginning Balance $ 13,453.08
Additions 306.00 Interest Paid Year -To -Date .30
F7 PSP Reductions 26.00 Interest Paid During
lID r Ending Balance AvokulmownTax Tax Yeal 2009 $ 3.25
----------------------------------------------------------------------------------
checking Deposits Amount
Detail 3/01 Deposit $ 146.00
3/01 Deposit 50.00
3/09 Deposit 10.00
3/15 Deposit 100.00
Checks
Number Reference Amount Data Number Reference Amount Date
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxzxxxxx xxxxxxxxxxx xxxxx xxxxxxzzxxxzxxxxxxxxxxxxx
2507 9950834738 26.00 3/17
Checking
Onto
Balance
Date
Balance Data Balance
Balance
xxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxx
History
3/01
$ 13,649.08
3/15
13,759.08
3/09
13,659.08
3/17
13,733.08
RBC Banke'
0
FOUR CHAPLAINS MONUMENT, IRC, INC -
102 ROYAL OAK DRIVE AFT 106 DANK USE
VERO BEACH, FL 32962-3015 00000
T MS
0.0000
C-0602
2/28/10
ACCT# -
February 1, 201-ftij 2010 Page 1 of 1
_______ ______
For account inquiries, please call 1-800-236-8872 or log in to web Banking at
.w,rbcbankusa.com.
------------------------------------------------------------------------------------
Checking
Summary Business 150 checking 11
Beginning Balance $ 9,428.08
-s ♦ 4,025.00 Interest Paid Year -To -Date .30
Reductions - .00 Interest Paid During
Ending Balance 8jjjpjMVgjft Tax Year 2009 $ 3.25
Checking
Deposits
Amount
Detail
2/05 Deposit
$ 4,000.00
2/23 Deposit
25.00
Checking
Date Balance
Date Balance
Date Balance
Balance
xxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxx
History
2/05 $ 13,428.08
2/23 13,453.08
RBC Bank"
FOUR CHAPLAINS MONUMENT, IRC, INC.
102 ROYAL OAK DRIVE APT loft BANK USE
VERO BEACH, FL 32962-3015 00000
T MS
D=O000
C-0001
1/31/10
ACC19 -
January 1, 2010_-_WMI 010 --Page 1 of 1
___________---- ___-------- __________________________________________________ - - -__
For account inquiries, please call 1-800-236-8872 or log in to Web Banking at
www. rbcba.kus..com.
______________________________________________________________________________________________
Checking
Summary Business 150 Checking
0
Amount
Detail
1/25 Deposit
Beginning Balance
$ 9,377.78
Interest
Paid
This Period
$ 38
Additions a
50.30
Interest
Paid
Year -To -Date
.30
Reductions -
.00
Interest
Paid
During
Endrng Balance
amnow
Tax Year 2009
$ 1.25
Checking
Deposits
Amount
Detail
1/25 Deposit
$ 50.00
1/27 Interest Paid on
Checking Account
.30
Checking
Date Balance
Date Balance
Date Balance
Balancex
xxxxxxxxxxxxxxxxxx
xxxxxxxxxxkxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxx
History
1/25 $ 9,427.78
1/27 9,428.08
www.sunbiz.org - Department of State
Page 1 of 2
Previous on List Next on List Return To List JEn6ty Name Search
Events No Name History Submit
Detail by Entity Name
Florida Non Profit Corporation
FOUR CHAPLAINS MONUMENT, IRC, INC.
Filing Information
Document Number N07000011988
FEVEIN Number
Data Filed
12/142007
State
FL
Status
ACTIVE
Effective Date
12/14/2007
Last Event
REINSTATEMENT
Event Date Filed
01/192011
Event Effective Date
NONE
Principal Address
101 ISLAND SANCTUARY
VERO BEACH FL 32963
Changed 01/1812012
Mailing Address
101 ISLAND SANCTUARY
VERO BEACH FL 32963
Changed 0111812012
Registered Agent Name & Address
WAPNICK, LARRY
101 ISLAND SANCTUARY
VERO BEACH FL 32963 US
Name Changed: 01/18/2012
Address Changed: 01/182012
Officer/Director Detail
Name & Address
Title TREA
HEATON, ERNESTL
102 ROYAL OAK DR #106
VERO BEACH FL 32962
Title PRIES
WAPNICK, LARRY
http://smbiz.org/scripts/cordet.exe?action=DETFIL&inL_doe_number—NO700001198... 2/17/2012
w .sunbiz.org - Department of State Page 2 of 2
101 ISLAND SANTUARY
VERO BEACH FL 32963
Title PURL
RIGBY, ARDRA
8465 59TH AV
WABASSO FL 32970
Annual Reports
Report Year Filed Data
2010 01/192011
2011 01/192011
2012 01/182012
Document Images
01/18/2012-6NNUALREPORT
View image in PDF format
011192011 —REINSTATEMENT
View image in PDF format
03111/2009 — ANNUAL REPORT
View image in PDF format
07/242008 —ANNUAL REPORT
View image in PDF format
0710812008.—ANNUAL REPORT
View image in PDF format I
12/14/2907 — D9meslc Non -Profit View image in PDF format
Note: This is not official record. See documents if question of conflict
Previous on List Next on Ust Returnjo-L_st Entity Name Search
Events No Name History Submit
I name I Conrad us I Dominent Searthoa I FRImg Services I Forms 1 Halo I
CopvNght€ and Privatt Policos
SWto of Forks , Department of State
http://sunbiz.org/scripts/cordet.exe?action=DETFIL&inq_doe_number—NO700001198... 2/17/2012
2012 NOT-FOR-PROFIT CORPORATION ANNUAL REPORT FILED
DOCUMENT# N07000011988 Secretary' of State
Entity Name: FOUR CHAPLAINS MONUMENT, IRC, INC.
Current Principal Place of Business: New Principal Place of Business
102 ROYAL OAK DR
101 ISLAND SANCTUARY
106
VERO BEACH, FL 32963
VERO BEACH, FL 32962
Current Mailing Address:
New Mailing Address:
102 ROYAL OAK DR
101 ISLAND SANCTUARY
106
VERO BEACH, FL 32963
VERO BEACH, FL 32962
FEN Number: 264678390 FEI Number Applied For l I
FO Number Not Applieable l I contrasts of Status Desired l I
Name and Address of Current Registered Agent:
Name and Address of New Registered Agent:
HEATON, ERNEST L
WAPNICK, LARRY
102 ROYAL OAK DR
101 ISLAND SANCTUARY
106
VERO BEACH, FL 32963 US
VERO BEACH, FL 32962 US
The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both,
in the State of Florida.
SIGNATURE: LARRY WAPNICK
0111 8/2 01 2
Electronic Signature of Registered Agent
Date
OFFICERS AND DIRECTORS:
Tek: TREA
Name: HEATON, ERNESTL
Address: 102 ROYAL OAK DR #106
City -St -21p: VERO BEACH, FL 32882
THIS: FRES
Name: WAPNICK LARRY
Address: 101 ISLAND SANRIARY
City -St -Zip: VERO BEACH, FL 32883
Tick: FUBL
Name: RIGBY. ARDRA
Address: 8/8668111 AV
( iAy-Sl-Zlp: WABAS60. FL 32970
I hereby certify Nat the information indicated on this report or supplemental report is true and accurate and that my electronic
signature shall have the same legal effect as if made under oath; that I am an officer or director of the corporation or the receiver
or trustee empowered to execute this report as required by Chapter 617, Florida Statutes; and that my name appears above, or
on an attachment with all other like empowered.
SIGNATURE: LARRY WAPNICK P 011180012
Electronic Signature of Signing Officer or Director Date