Form Ss - 6039 Quarterly Financial Report
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1
2State of Tennessee
W A R N I N G : F a l s e o r m i s l e a d i n g s t a t e m e n t s subject to maximum
$5,000 civil penalty. T.C.A. §48-101-514
Date Received
Department of State
QUARTERLY FINANCIAL REPORT
Division of Charitable Solicitations & Gaming
William R. Snodgrass Tennessee Tower
th
312 Rosa L. Parks Avenue , 8
Floor
Nashville, TN 37243
(615) 741-2555 / (615) 253-5173 - fax
___________________________________________________________________
NSTRUCTIONS: A newly registered organization in its first year of operation must complete a quarterly
I
financial report at the end of each quarter of its current fiscal year. The report is due within thirty (30) days
of the end of each quarter.
_____________________________________________________________________________________
1. Organization Name: ____________________________________________________________
2. Registration Number: _________________________
st
nd
3. Financial Period
:
1
Quarter
2
Quarter
rd
th
3
Quarter
4
Quarter
_______ _______ _______
TO _______ _______ _______
Month
Day
Year
Month
Day
Year
_____________________________________________________________________________________
I. REVENUE
Gross Contributions:
$ ______________________
Other Revenue:
$ ______________________
Total Revenue
$ ______________________
II. EXPENSES
Program Services:
$ _____________________
Fundraising:
$ _____________________
Administrative:
$ _____________________
Other (Attach Schedule)
$ _____________________
Total Expenses
$ _____________________
_____________________________________________________________________________________
Number of continuation pages attached: _________________
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