Form Ss-6058 - Summary Of Financial Activities Of An Exempt Charitable Organization printable pdf download

Form Ss-6058 - Summary Of Financial Activities Of An Exempt Charitable Organization

WARNING: False or misleading statements

OFFICE USE ONLY

Subject to maximum $5,000 penalty. T.C.A. §48-101-502(a)(2)

State of Tennessee

Date Stamped

Department of State

SUMMARY OF FINANCIAL

Division of Charitable Solicitations

ACTIVITIES OF AN EXEMPT CHARITABLE

312 Eighth Avenue North

Floor, William R. Snodgrass Tower

ORGANIZATION

Nashville, TN 37243

(615) 741-2555

INSTRUCTIONS

A charitable organization must use this form to report financial activities or attach a copy of your most recently-completed

IRS Form 990. If you have not completed a full year of operation, you must submit a proposed budget for your first year of

operation.

Gross revenue includes all monies received by your organization from all sources, before expenses are deducted.

Contributions raised by a professional solicitor must be reported as gross revenue received by your organization.

This form, including attachments, is a public record.

NAME OF ORGANIZATION: ___________________________________________________________________________

FISCAL YEAR ENDING: ____________________________________

FEIN: ________________________________

GROSS REVENUE

CONTRIBUTIONS FROM THE PUBLIC:

1. Direct and Indirect………………………………… $____________

2. Special Events………………………………………$____________

3. United Way or Other Federated Fundraisers……$____________

MEMBERSHIP DUES……………………………………$____________

GOVERNMENT GRANTS……………………………… $____________

OTHER REVENUE……………………………………… $____________

TOTAL GROSS REVENUE:………………………………………………………………………… $_________________

EXPENSES

PROGRAM SERVICES………………$_____________

FUND RAISING……………………… $_____________

ADMINISTRATIVE……………………$_____________

OTHER…………………………………$_____________

TOTAL EXPENSES:…………………………………………………………………………………$_________________

EXCESS (DEFICIT) OF REVENUE OVER EXPENSES…………………………………………$_________________

Form Ss-6058 - Summary Of Financial Activities Of An Exempt Charitable Organization