Charitable Organization Financial Statement Form - Arizona Secretary Of State

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REGISTRATION #_____________
D
N
W
T
S
State of Arizona
O
OT
RITE IN
HIS
PACE
Charitable Organization Financial Statement
Mail to: Arizona Secretary of State Ken Bennett
Attention: Business Services, Charities Division
400 West Congress, 2nd Floor Room 252, Tucson, AZ 85701
(602) 542-6187 (800) 458-5842 (within Arizona)
Website:
F
O
U
O
– R
. 07/26/12
OR
FFICE
SE
NLY
EV
C
O
F
S
(
A.R.S. § 44-6552)
HARITABLE
RGANIZATION
INANCIAL
TATEMENT
About this form
How to complete this form
This form may be used to file a Charitable Organization
This form must be written legibly or computer generated for
Financial Statement under A.R.S. § 44-6552. A copy of this
accuracy. This form has been designed to be filled out and
law is available at .
printed online at the website referenced above.
Read this statement carefully, and fill in all blank spaces. If an
Filing Fee: None
item is not applicable, write “N/A” in the space.
Alternative to filing this statement: Instead of using this
File by mail to the address above or,
form a charitable organization can file its IRS 990 Form for the
Return in person at the following locations:
previous year under A.R.S. § 44-6552(F)(1).
PHOENIX - State Capitol
TUCSON - Arizona State
Executive Tower
Complex Building
Notarization of this Financial Statement: This Financial
1700 W. Washington Street
400 W. Congress
Statement requires notarized signatures of any TWO officers
First Floor, Room 103
Second Floor, Room 252
at the end of this document. Notarization services are available
These locations are open Monday through Friday, 8 a.m. to 5 p.m.
at the Secretary of State’s Office at the addresses listed under,
except state holidays.
“Return in Person.”
Please Type or Print
1. Charitable Organization Contact Information
Name of Charitable Organization
Doing Business As (DBA)
Charitable Organization Business Address
Business Address (include street, box or suite number)
City
State
Zip Code
Business Phone Number (include area code)
Charitable Organization Mailing Address
Mailing Address (include street, box or suite number)
City
State
Zip Code
Internet Address
Toll Free Number
2. This Statement is for the FISCAL Year
Beginning on (month/day/year):
And ending on (month/day/year):
3. Income Statement ~ Contributions, gifts, and similar amounts received (In U.S. dollars)
Public Donations:
Grants:
Other Revenue:
TOTAL:
Office Form SOSBSCharity_Financial_Statement.doc
C hari t abl e Fi nanci al St at ement
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