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Annual Report of a Board Member of a Hospital or Medical Services Corporation (Tennessee)

This is an annual report of a hospital or medical services corporation in Tennessee. The form provided here is simply a sample of what the actual Form SS 4497 looks like.

Filing Fee: $20.00
Filing Deadline: January 10

CONTROL NUMBER ________________________

Mail or deliver to: Secretary of State
Corporate Filings
312 Eighth Avenue North
6th Floor, William R. Snodgrass Building
Nashville, TN 37243
Telephone Contact: (615) 741-0537

ANNUAL REPORT OF A BOARD MEMBER OF A
HOSPITAL OR MEDICAL SERVICES CORPORATION
FILED PURSUANT TO TCA 56-29-105

TCA 56-29-105 requires each board member of a corporation organized and governed by Title 56, Chapter 29, to report to the Secretary of State: (1) all compensation received from the corporation, including payments for services actually rendered, (2) any conflict of interest the director has due to service on the corporation's board; and (3) all income received from any business interest that transacts business with or receives funds from a corporation organized and governed by Title 56, Chapter 29. The report must be filed annually by January 10 and will be retained by the Secretary of State for three (3) years.

1(a). Name of hospital or medical services corporation in which the undersigned serves as a board member:

________________________

1(b). Name of board member (printed or typed):

________________________

2(a). Compensation received as a board member of the corporation:

$________________________

2(b). Other payments received for services actually rendered to the corporation (such as legal counsel, medical service, accounting or other required service.)

SERVICES RENDERED ________________________

COMPENSATION ________________________


SERVICES RENDERED ________________________

COMPENSATION ________________________

3. Conflicts of interest due to service as a board member of the corporation.

________________________

4. All income received from any corporation, partnership or other business interest that transacts business with or receives funds from any hospital or medical services corporation governed by TCA 56-29-101 et.seq. listed by source and amount.

SOURCE ________________________

AMOUNT ________________________


SOURCE ________________________

AMOUNT ________________________

Signature ________________________

Date ________________________

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