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Unincorporation Form

Community Counsel Program

Unincorporated Group Client Application

(Proposed) Name of Organization:

Address:

City:

State:

Zip Code:

Telephone:

Fax:

E-mail:

Contacts:

Primary Contact:

Primary Contact Phone #:

Primary Contact Address:

Primary Contact City:

Primary Contact State:

Primary Contact Position/Office:

Primary Contact E-mail:

Secondary Contact:

Secondary Contact Phone #:

Secondary Contact Address:

Secondary Contact City:

Secondary Contact State:

Secondary Contact Position/Office:

Secondary Contact E-mail:

Purpose of the Organization:

Geographic Target Area:

County:

Will the Organization serve primarily low income people?

Yes
No

If so, approx. number annually:

Is the Organization financially unable to retain and pay for a private attorney?

Yes
No

Has the Organization retained and paid an attorney in the past 12 months?

Yes
No

If so please list:

General Statement of problem:

How did you learn about the Community Counsel Program?

I certify that the above information is correct and I am authorized to file this Application.

By:

Office/Title:

Date:

Signature (Print Name):

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We are a 501(C) (3), a copy of the official charitable organization registration and financial information may be obtained from the Division of Consumer Services by calling toll-free (1-800-435-7352) within Florida. Registration does not imply endorsement, approval or recommendation by the state. Registration #CH1969.

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