Form Char410 - Registration Statement For Charitable Organizations - 2010 Page 3
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3Part G - Organization Activities
1. Month the annual accounting period ends (01-12)
2. NTEE code
3. Date organization began doing each of following in New York State:
a. conducting activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __
b. maintaining assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __
c. soliciting contributions (including from residents, foundations, corporations, government agencies, etc.) . . . . . . . . . __ __ / __ __ / __ __ __ __
4. Describe the purposes of your organization
5. Has your organization or any of your officers, directors, trustees or key employees been:
G
G
a. enjoined or otherwise prohibited by a government agency or court from soliciting contributions? . . . . . . . . . . . . . . . . . . . . . . . . .
Yes*
No
* If “Yes”, describe:
G
G
b. found to have engaged in unlawful practices in connection with the solicitation or administration of charitable assets? . . . . . . . .
Yes*
No
* If “Yes”, describe:
G
G
6. Has your organization’s registration or license been suspended by any government agency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes*
No
* If “Yes”, describe:
7. Does your organization solicit or intend to solicit contributions (including from residents, foundations, corporations, government
G
G
agencies, etc.) in New York State? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes*
No
* If “Yes”, describe the purposes for which contributions are or will be solicited:
8. List all fund raising professionals (FRP) that your organization has engaged for fund raising activity in NY State (attach additional sheets if
necessary)
Mailing address (number and street, room/suite,
Type of FRP
Name
city or town, state or country and zip+4)
Dates of contract
(see instructions for definitions)
Start date:
_ _ / _ _ / _ _ _ _
PFR . . . . . . . . . . . . . . . . G
FRC . . . . . . . . . . . . . . . . G
End date:
_ _ / _ _ / _ _ _ _
CCV . . . . . . . . . . . . . . . . G
Start date:
_ _ / _ _ / _ _ _ _
PFR . . . . . . . . . . . . . . . . G
FRC . . . . . . . . . . . . . . . . G
End date:
_ _ / _ _ / _ _ _ _
CCV . . . . . . . . . . . . . . . . G
Start date:
_ _ / _ _ / _ _ _ _
PFR . . . . . . . . . . . . . . . . G
FRC . . . . . . . . . . . . . . . . G
End date:
_ _ / _ _ / _ _ _ _
CCV . . . . . . . . . . . . . . . . G
Part H - Federal Tax Exempt Status
1. If applicable, list the date your organization:
a. applied for tax exempt status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __
b. was granted tax exempt status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __
c. was denied tax exempt status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __
d. had its tax exempt status revoked . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __
2. Provide Internal Revenue Code provision:
501(c)( ___ )
Page 3 of 3
Form CHAR410 (2010)
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