Form 1943 - Affidavit In Lieu Of Annual Financial Report Page 3
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413.
Has any of the information your organization previously submitted to the division changed
(i.e. name of the organization, address of the principal office, address of any Wisconsin branch
Yes
No
offices, accounting period, names of persons who have final authority for custody or final
distribution of contributions, articles, by-laws, statement of purpose, etc.)?
If YES, describe the changes below. If the organization’s corporate name has changed, also attach a copy of the name
change amendment. (Please note that you do not need to provide this information if, as required by law, you already
submitted the information to the division within 30 days after the date of the change.)
14.
Is your organization authorized by any other state/governmental authority to solicit contributions?
Yes
No
15.
During the past year, has your organization had its authority to solicit contributions denied,
Yes
No
suspended, revoked, or enjoined by a court or other governmental authority?
If YES, provide a detailed statement of explanation.
16. Does your organization intend to accumulate an increasing surplus in net assets, rather than spend
Yes
No
current revenue on the organization’s stated purpose?
If YES, please explain.
17. Did the registrant make a grant, award, or contribution to any organization in which any of the
Yes
No
registrant’s officers or directors hold an interest; or was the registrant a party to any transaction in
which any of its directors, trustees or officers has a material financial interest; or did any officer or
director of the registrant receive anything of value not reported as compensation?
If YES to any of the above, please explain.
18. Check the box to the right if the registrant is a sole proprietor who wishes for his/her individual personal
identifiers to be excluded from any lists which may be distributed to third parties. Individual personal identifiers
include: social security number, telephone number, street name and number, email address, and post-office box.
ATTACHMENTS
The following items must be attached to this affidavit. (Note: If you are submitting this form with your initial application, DO NOT
submit the following attachments. Submit the attachments cited in the application form instead).
A. List of all officers, directors, trustees, and principal salaried employees – The list must include each
individual’s name, address, and title.
Please note that “principal salaried employees” refers to the chief
administrative officers of your organization, but does not include the heads of separate departments or smaller units
within the organization.
B. A list of states that have issued a license, registration, permit, or other formal authorization to the
organization to solicit contributions.
CO WI SUPPLEMENT TO FINANCIAL REPORT
Page 3 of 5
DFI/LFS/1943 (R 4/2014)
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Parent category: Business