Fillable Form 1952 - Supplement To Financial Report (Page 5 of 5) in pdf

Form 1952 - Supplement To Financial Report Page 5

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C. IRS Form #990, 990EZ, or 990-PF. Do not include Schedule B of the 990.

(Note: If you file an IRS Form 990-N, you cannot use this form. You must complete a Form #308 or Form #1943

instead.)

D. Audited Financial Statements if the organization received $400,000 or more in contributions during its fiscal

year. The financial statements must be prepared in accordance with generally accepted accounting principles and

be accompanied by the opinion of an independent certified public accountant.

E. Reviewed Financial Statements if the organization received between $200,000 - $399,999 in contributions during

its fiscal year. The financial statements must be prepared in accordance with generally accepted accounting

principles by an independent certified public accountant. Audited financial statements are also acceptable.

CERTIFICATION

This document MUST be signed by the chief fiscal officer. Two different officer signatures required.

We swear and affirm that we have reviewed this report, including the accompanying schedules and statements, and to the best of

our knowledge the information furnished is true, correct, and complete.

_______________________________________________

__________________________________________________

Signature of President or Authorized Officer

Date

Signature of Chief Fiscal Officer

Date

SUBSCRIBED AND SWORN TO BEFORE ME

THIS ________ DAY OF _________________, ________

THIS ________ DAY OF _________________, ___________

________________________________________________

___________________________________________________

(Notary Public)

My Commission Expires: ___________________________

My Commission Expires: ______________________________

RETURN MATERIALS TO:

Department of Financial Institutions

Division of Banking

Mailing Address:

Street Address:

PO Box 7876

201 West Washington Avenue, Suite 500

Madison, Wisconsin 53707-7876

Madison, Wisconsin 53703

Notice: Completion of this form is required under Section 202.12, Wisconsin Statutes. Failure to comply may result in further action by our

Department. Personal information you provide may be used for secondary purposes.

This document can be made available in alternate formats upon request to qualifying individuals with disabilities.

CO WI SUPPLEMENT TO FINANCIAL REPORT

Page 5 of 5

DFI/LFS/1952 (R 3/2014)

Form 1952 - Supplement To Financial Report Page 5

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