Form Ss-6001 - Application For Registration Of A Charitable Organization Page 2
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213. List all chapters, branches, and affiliates of the organization located in Tennessee: Reporting Financial Activity? Yes
No
Name of Chapter:
Branch:
Affiliate:
Address:
City:
State:
Zip Code:
14. Is the organization ever been registered in any other state(s): Yes
No
If yes, attach a list of the other states.
15. Has the organization ever been enjoined or prohibited by any court from soliciting contributions? Yes
No
If yes, attach a detailed explanation.
16. List the name and address of individual(s) who have final responsibility for the custody of contributions:
Name:
Address:
City:
State:
Zip Code:
Name:
Address:
City:
State:
Zip Code:
17. List the name and address of individual(s) who have responsibility for the final distribution of contributions:
Name:
Address:
City:
State:
Zip Code:
Name:
Address:
City:
State:
Zip Code:
18. Does your organization contract with or otherwise engage the services of any outside fund-raising professional (such
as a “professional fund-raiser,” “paid solicitor,” “fund raising counsel,” or “commercial co-venturer”)? Yes
No
If yes, attach a list including their names, addresses (street and P.O.), telephone numbers, and location of offices used to perform
work on behalf of the organization. Additionally, submit a true copy of any contract with the listed entity.
19. For what purpose will the organization use the contributions? (Be specific)
This document must be signed by two authorized officers, one of whom shall be the Chief Fiscal Officer.
I certify that the statements in this registration statement and all supplemental forms, documents and continuation sheets are
true and correct to the best of my knowledge and belief.
Signature of Authorized Officer:
Signature of Authorized Officer:
Print Name:
Print Name:
Title:
Title:
Date:
Date:
SS-6001 (Rev. 6/13)
RDA 1745
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