Form Char410 - Registration Statement For Charitable Organizations

Form Char410 - Registration Statement For Charitable Organizations - 2010 Page 2

Part F - Organization Structure

1. Incorporation / formation

a. Type of organization:

b. Type of corporation if New York not-for-profit corporation

Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Limited liability company (LLC) . . . . . . . . . . . . . . . . . . . . . . . . .

Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c. Date incorporated if a corporation or formed if other than a corporation

Sole proprietorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

__ __ / __ __ / __ __ __ __

Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unincorporated association . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d. State in which incorporated or formed

Other * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

* If Other, describe:

2. List all chapters, branches and affiliates of your organization (attach additional sheets if necessary)

Mailing address (number and street, room/suite,

Name

Relationship

City or town, state or country and zip+4)

3. List all officers, directors, trustees and key employees

Mailing address (number and street, room/suite,

End of term

Name

Title

city or town, state or country and zip+4)

(if applicable)

_ _ / _ _ / _ _ _ _

4. Other Names and Registration Numbers

a. List all other names used by your organization, including any prior names

b. List all prior New York State charities registration numbers for the organization, including those from the New York State Attorney General’s

Charities Bureau or the New York State Department of State’s Office of Charities Registration

Page 2 of 3

Form CHAR410 (2010)

Form Char410 - Registration Statement For Charitable Organizations - 2010 Page 2