Form 1943 - Affidavit In Lieu Of Annual Financial Report
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STATE OF WISCONSIN
Chapter 202, Wis. Stats.
Division of Banking
Subchapter II
Department of Financial Institutions
Mailing Address:
PO Box 7876
Telephone: (608) 267-1711
Madison, WI 53707-7876
Fax: (608) 267-6889
Courier Address:
201 W. Washington Ave.
Suite 500
FORM #1943 – AFFIDAVIT IN LIEU
Madison, WI 53703
OF ANNUAL FINANCIAL REPORT
Purpose: Charitable organizations that are registered, or are required to be registered, with the Department of Financial
Institutions – Division of Banking (“division”) must file an annual financial report with the division within 9 months after the
organization’s fiscal year-end unless the organization qualifies for an exemption from the annual filing requirement.
This Affidavit in Lieu of Annual Financial Report form should be used by organizations that qualify for an exemption from the
annual report filing requirement. Organizations that are or may be exempt include:
Organizations that received $5,000 or less in contributions during their most recently completed fiscal year.
Organizations that operate solely in the county in which their principal office is located and that received less than
$50,000 in contributions during their most recently completed fiscal year.
The Affidavit in Lieu of Annual Financial Report must be submitted to the division within 9 months after an organization’s
fiscal year-end.
Print or type the information requested in the spaces provided.
1. Name of charitable organization and any trade names or DBA (doing business as) names the organization uses when soliciting.
2. WI Charitable Organization Registration Number:
3. Federal Employer Identification Number:
4. Provide the following information for the organization’s headquarters office, if any:
Street:
City:
State:
Zip:
Daytime Phone Number:
5. Provide the organization’s mailing address if different than above.
Street:
P.O. Box:
City:
State:
Zip:
6. Provide the following information for the organization’s Wisconsin office, if any. Attach additional pages, if the organization
has more than one Wisconsin office. This item does not have to be completed if the headquarters office noted above is the
only Wisconsin office.
Street:
City:
State:
Zip:
Daytime Phone Number:
CO WI SUPPLEMENT TO FINANCIAL REPORT
Page 1 of 5
DFI/LFS/1943 (R 4/2014)
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