Form 1952 - Wisconsin Supplement To Financial Report On Form Other Than Form #308 printable pdf download

Wisconsin Department of Safety and Professional Services

Mail To:

P.O. Box 8935

1400 E. Washington Avenue

Madison, WI 53708-8935

Madison, WI 53703

FAX #:

(608) 261-7083

E-Mail: web@dsps.wi.gov

Phone #:

(608) 266-2112

Website:

DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING

WISCONSIN SUPPLEMENT TO FINANCIAL REPORT ON FORM OTHER THAN FORM #308

This form requires a Federal Form 990, and 2 different signatures.

PLEASE TYPE OR PRINT IN INK

NAME OF ORGANIZATION

WISCONSIN REGISTRATION NUMBER

ADDRESS (NUMBER AND STREET) OR P.O. BOX

FEDERAL EMPLOYER I.D. NUMBER

CITY OR TOWN, STATE, ZIP CODE

ORGANIZATION’S DAYTIME PHONE

NUMBER

(

)

INDICATE ORGANIZATION TYPE

ACCOUNTING METHOD

___ Cash

___ Civic & Social Action

___ Health Services

___ Culture

___ Other (Specify)

___ Accrual

___ Education & Research

___ Human Services

___ Other

ACCOUNTING PERIOD

Beginning Date ________________________

Ending Date _________________________

Public Support .....................................................................................................................................................

(Enter total direct public support such as: contributions, gifts, grants-but not government grants-and

bequests received directly from the public.

This line includes indirect public support, such as:

contributions received through solicitation campaigns conducted by federated fund-raising agencies like

United Way, or affiliate organizations.)

Other Revenues ...................................................................................................................................................

Total Revenue (line 1 plus line 2) ........................................................................................................................

Expenses:

Expenses Allocated to Program Services ..................................................

Expenses Allocated to Management and General .....................................

Expenses Allocated to Fund-raising .........................................................

Expenses Allocated to Payments to Affiliates ..........................................

Total Expenses .............................................................................................................................................

Excess or Deficit (line 3 minus line 4e) ...............................................................................................................

Net Worth at Beginning of Year ..........................................................................................................................

Other Changes in Net Assets or Fund Balances (See 990, part XI, line 5) ...........................................................

Net Worth at End of Year ....................................................................................................................................

PLEASE TYPE OR PRINT IN INK

NAME OF INDIVIDUAL TO CONTACT REGARDING INFORMATION ON THIS FORM

DAYTIME TELEPHONE NUMBER

(

)

ADDRESS (NUMBER AND STREET)

CITY OR TOWN, STATE, ZIP CODE

#1952 (Rev. 5/12)

-OVER-

Ch. 440, Stats.

Committed to Equal Opportunity in Employment and Licensing