Filer EIN ______________________________________

State ______________________________________

State ID ______________________________________

1. Organization's legal name_______________________________________________________________________

If changed since prior filings, previous name used _________________________________________________

All other name(s) used______________________________________________________________________

 

2.

(A) Street address ____________________________________________________________________________

City ____________________________________________________________________________________

County __________________________________________________________________________________

State ___________________________________________________________________________________

Zip Code ________________________________________________________________________________

 

(B) Mailing address (if different) __________________________________________________________________

City ____________________________________________________________________________________

County __________________________________________________________________________________

State ___________________________________________________________________________________

Zip Code ________________________________________________________________________________

 

3. Telephone number(s) __________________________________________________________________________

Fax number(s) ____________________________________________________________________________

E-mail _________________________________________________________________________________

Web site ________________________________________________________________________________

 

4. Names, addresses (street & P.O.), telephone numbers of other offices/chapters/branches/affiliates (attach list).

5. Date incorporated _______________________________ State of incorporation ______________________________

Fiscal year end: day/month ________________________________________________________________________

 

6. If not incorporated, type of organization, state, and date established __________________________________________

________________________________________________________________________________________________________

7. Has organization or any of its officers, directors, employees or fund raisers:

A. Been enjoined or otherwise prohibited by a government agency/court from soliciting? Yes ___ No ___

B. Had its registration denied or revoked? Yes ___ No ___

C. Been the subject of a proceeding regarding any solicitation or registration? Yes ___ No ___

D. Entered into a voluntary agreement of compliance with any government agency or in a case before a court or administrative agency?

Yes ___ No ___

E. Applied for registration or exemption from registration (but not yet completed or obtained) Yes ___ No ___

F. Registered with or obtained exemption from any state or agency? Yes ___ No ___

G. Solicited funds in any state? Yes ___ No ___

If "yes" to 7A, B, C, D, E, attach explanation.

If "yes" to 7F & G, attach list of states where registered, exempted, or where it solicited, including registering agency, dates of registration, registration numbers, any other names under which the organization was/is registered, and the dates and type (mail, telephone, door to door, special events, etc.) of the solicitation conducted.

 

8. Has the organization applied for or been granted IRS tax exempt status? Yes ___ No ___

If yes, date of application _ _ _ _ OR date of determination letter _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .

If granted, exempt under 501(c) _ _ _ _ Are contributions to the organization tax deductible? Yes ___ No ___

9. Has tax exempt status ever been denied, revoked, or modified? Yes ___ No ___

10. Indicate all methods of solicitations:

Mail ___Telephone ___ Personal Contact ___ Radio/TV Appeals ___

Special Events ___ Newspaper/Magazine Ads ___ Other(s) ___ (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

11. List the NTEE code(s) that best describes your organization _ _ _ _ _ , _ _ _ _ _ , _ _ _ _ _

12. Describe the purposes and programs of the organization and those for which funds are solicited (attach separate sheet if necessary).

_______________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________

13. List the names, titles, addresses, (street & P.O.), and telephone numbers of officers, directors, trustees, and the principal salaried executives of organization (attach separate sheet).

14.

(A) (1) Are any of the organization's officers, directors, trustees or employees related by blood, marriage, or adoption to:
(i) any other officer, director, trustee or employee OR
(ii) any officer, agent, or employee of any fundraising professional firm under contract to the organization OR
(iii) any officer, agent, or employee of a supplier or vendor firm providing goods or services to the organization?
Yes ___ No ___
(2) Does the organization or any of its officers, directors, employees, or anyone holding a financial interest in the organization have a financial interest in a business described in (ii) or (iii) above OR serve as an officer, director, partner or employee of a business described in (ii) or (iii) above? Yes ___ No ___
(If yes to any part of 14A, attach sheet which specifies the relationship and provides the names, businesses, and addresses of the related parties). Yes ___ No ___

(B) Have any of the organization's officers, directors, or principal executives been convicted of a misdemeanor or felony? (If yes, attach a complete explanation.) Yes ___ No ___

 

15. Attach separate sheet listing names and addresses (street & P.O.) for all below:

Individual(s) responsible for custody of funds.

 

Individual(s) responsible for distribution of funds.

 

Individual(s) responsible for fund raising.

 

Individual(s) responsible for custody of financial records.

 

Individual(s) authorized to sign checks.

 

Bank(s) in which registrant's funds are deposited (include account number and bank phone number).

 

16. Name, address (street & P.O.), and telephone number of accountant/auditor.

Name _______________________________________________________________________________________

Address _____________________________________________________________________________________

City ___ _______________ State __________

Zip Code ____________________ Telephone ______________________

Method of accounting ___________________________________________________________________________

 

17. Name, address (street & P.O.), and telephone number of person authorized to receive service of process. This is a state-specific item. See instructions.

Name _______________________________________________________________________________________

Address _____________________________________________________________________________________

City ____________________ State ____________________

Zip Code ____________________

18.

(A) Does the organization receive financial support from other nonprofit organizations (foundations, public charities, combined campaigns, etc.) Yes ___ No ___

(B) Does the organization share revenue or governance with any other non-profit organization? Yes ___ No ___

(C) Does any other person or organization own a 10% or greater interest in your organization OR does your organization own a 10% or greater interest in any other organization?Yes ___ No ___

(If "yes" to A, B or C, attach an explanation including name of person or organization, address, relationship to your organization, and type of organization.)

19. Does the organization use volunteers to solicit directly? Yes ___ No ___

Does the organization use professionals to solicit directly? Yes ___ No ___

20. If your organization contracts with or otherwise engages the services of any outside fundraising professional (such as a :professional fundraiser," "paid solicitor," "fund raising counsel," or "commercial co-venturer"), attach list including their names, addresses (street & P.O.), telephone numbers, and location of offices used by them to perform work on behalf of your organization. Each entry must include a simple statement of services provided, description of compensation arrangement, dates of contract, date of campaign/event, whether the professional solicits on your behalf, and whether the professional at any time has custody or control of donations.

21. Amount paid to PFR/PS/FRC during previous year: $ ____________________

22. For the most recent fiscal year, please provide the following:

(A) Total contributions: $ ____________________

(B) Program service expenses: $ ____________________

(C) Management & general expenses: $ ____________________

(D) Fundraising expenses: $                             

(E) Total Expenses: $                             

(F) Fundraising expenses as a percentage of funds raised: ____________________ %

(G) Fundraising expenses plus management and general expenses as a percentage of funds raised: ____________________ %

(H) Program services as a percentage of total expenses:                              %

 

Under penalty of perjury, we certify that the above information and the information contained in any attachments or supplement is true, correct, and complete.

Sworn to before me on (or signed on) ____________________ , 20 _______

________________________________________

Notary public (if required)

________________________________________

Name (printed)

____________________________________________________________

Name (signature)

_______________________________________________________

 

Title (printed)

_______________________________________________________

Name (printed)

______________________________________________________________

Name (signature)

_______________________________________________________

Title (printed)

_______________________________________________________

Attachments may be prepared as one continuous document or as separate pages for each item requiring elaboration. In either case, please number the response to correspond with the URS item number.

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