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MISSISSIPPI SECRETARY OF STATE

SUPPLEMENT TO UNIFIED REGISTRATION STATEMENT

& ANNUAL FINANCIAL REPORT FORM (FORM FS)

INSTRUCTIONS

FORM FS must be completed and be in agreement with financial information reported on IRS Form 990 or the filed financial statement. The registration will be rejected and returned if FORM FS is not complete and/or not in agreement with supporting documents.

1)�� An audited financial statement prepared by a certified public accountant and IRS Form 990 must be filed along with the Unified Registration Statement and Annual Financial Statement Form if the organization:

�� (A) Received contributions over $100,000;

�� (B) Engaged the services of a professional fund-raiser or fund-raising counsel; or if fundraising was conducted by persons who were paid for performing these services.

The Annual Financial Report form must be signed by both the president (or other authorized officer) and chief financial officer (See Section 79-11-507(1) of the Mississippi Charitable Solicitations Act).

2)�� A financial statement, audited or unaudited, and the IRS Form 990 or 990EZ (if filed) must be filed with the Unified Registration Form and Annual Financial Report form if the organization:

�� (A) Received contributions of less than $100,000;

�� (B) Did not engage the services of a professional fund-raiser /fund-raising counsel and if fundraising was conducted by persons who were unpaid for performing these services.

The Annual Financial Report Form must be signed by the president or other authorized officer (See Section 79-11-507(2) of the Mississippi Charitable Solicitations Act).

3)�� Organizations with contributions under $25,000 must complete the Annual Financial Report.� (See Section 79-11-507(3) of the Mississippi Charitable Solicitations Act).

��

�� The Annual Financial Report Form must be signed by the president or other authorized officer.

A separate Annual Financial Report must be filed for each local division, chapter or affiliate� the Organization� has included under its registration (See Section 79-11-503(7)).

Mississippi Secretary of State's Office

�� Charities Registration

�� P O Box 136

�� Jackson, MS� 39205-0136

(601) 359-1633 or 888-236-6167

�� REGISTRATION IS REQUIRED PRIOR TOANY SOLICITATION OF CONTRIBUTIONS

RENEWAL OF REGISTRATION

All registrations must renew annually. A complete unified registration statement and annual financial report form, along with all attachments, is due by the date on the Certificate of Registration issued by this Office.

NOTICE: MISSISSIPPI LAW DOES NOT ALLOW AN EXTENSION.

�� FORM FS

MISSISSIPPI SECRETARY OF STATE
�ANNUAL FINANCIAL REPORT FORM

��

NAME OF ORGANIZATION �� MISSISSIPPI REGISTRATION # C - _______

List person to whom correspondence regarding registration should be directed:

��

FORM FS must be completed and be in agreement with financial information reported on IRS Form 990 or the filed financial statement.� The registration will be rejected and returned if FORM FS is not complete and/or not in agreement with supporting documents.

FISCAL YEAR END ________________________��

1.�� RECEIPTS AND INCOME (REVENUE)

CONTRIBUTIONS (LIST SEPARATELY FOR EACH PROJECT OR SOURCE)

1.____________________________________________�� $__________________

2.____________________________________________�� __________________

3.____________________________________________�� __________________

4.____________________________________________�� __________________��

SUBTOTAL CONTRIBUTIONS�� . . . . . . . . . . . . . . . . . . . . .� . . . . . . $_________________

OTHER INCOME (MEMBERSHIP DUES, ENDOWMENTS, ETC.)

1.____________________________________________�� $_________________

2.____________________________________________�� _________________

3.____________________________________________�� __________________

SUBTOTAL OTHER INCOME� . . . . . . . . . . . . . . . . . . . . . . . . . . . .� $_________________

TOTAL RECEIPTS AND INCOME: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$____________________

2.�� EXPENSES

�� NET AMOUNT DEDICATED OR DISBURSED FOR EACH MAJOR PURPOSE, CHARITABLE OR OTHERWISE:

1. PROGRAM SERVICES (ITEMIZE BY CATEGORY)

�� PUBLIC EDUCATION PROGRAMS�� ___________________

�� RESEARCH�� ___________________

�� ___________________________�� ___________________

��

�� SUBTOTAL PROGRAM SERVICES . . . . . . . . . . . . . . . . . $_____________________

�� 2.� ADMINISTRATION (MANAGEMENT & GENERAL) . . . . . . . . . $_____________________

�� 3.� FUNDRAISING� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_____________________

�� 4.� PAYMENTS TO AFFILIATES� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_____________________

5.� OTHER�� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_____________________

TOTAL EXPENSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$___________________

List joint costs reported in Program Services from a combined educational campaign and fundraising solicitation:

Total Amount before allocation : _______________��

Amount allocated to Program Services:�� ____________________

Amount allocated to Fundraising:�� ____________________

Amount allocated to Management & General:�� ____________________

I CERTIFY THAT ALL INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

___________________________________________________________�� Sworn to and subscribed before me this the ��

SIGNATURE OF PRESIDENT OR�� DATE��

OTHER AUTHORIZED OFFICER �� ________ day of ____________________,� 20____

___________________________________________________________��

PRINTED OR TYPED NAME AND TITLE�� NOTARY PUBLIC

�� �� NOTARY SEAL

____________________________________________________________�� Sworn to and subscribed before me this the��

CHIEF FINANCIAL OFFICER�� DATE��

�� _______ day of __________________, 20____

____________________________________________________________

PRINTED OR TYPED NAME AND TITLE�� ________________________________________________

NOTARY PUBLIC