Form 1943 - Affidavit In Lieu Of Annual Financial Report Page 4
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4AFFIDAVITS
*Read the descriptions of Affidavit 1 and Affidavit 2, below. Complete the affidavit(s) that pertains to your organization.
AFFIDAVIT 1: AFFIDAVIT OF ORGANIZATION WITH CONTRIBUTIONS LESS THAN $5,000
We swear that the organization identified on page 1 will not be submitting Form #308, the Charitable Organization Annual
Report, for its most recently-completed fiscal year, ending _______________, ________, because contributions received during
that fiscal year did not exceed $5,000.
This document MUST be signed by the chief fiscal officer. Two different officer signatures required.
_______________________________________________
__________________________________________________
Signature of President or Authorized Officer
Date
Signature of Chief Fiscal Officer
Date
SUBSCRIBED AND SWORN TO BEFORE ME
SUBSCRIBED AND SWORN TO BEFORE ME
THIS ________ DAY OF _________________, ________
THIS ________ DAY OF _________________, ___________
________________________________________________
___________________________________________________
(Notary Public)
(Notary Public)
My Commission Expires: ___________________________
My Commission Expires: ______________________________
AFFIDAVIT 2: AFFIDAVIT OF ORGANIZATION WHICH SOLICITED CONTRIBUTIONS SOLELY IN ONE
COMMUNITY AND RECEIVED LESS THAN $50,000 IN CONTRIBUTIONS
We swear that the organization identified on page 1 solicits contributions solely within the county in which its principal office is
located and that it received less than $50,000 in contributions during its most recently completed fiscal year, ending
_______________, ________. Therefore, by filing this affidavit, we are (mark all that apply):
Seeking exemption from filing a financial report for that fiscal year and/or
Seeking exemption, for the current fiscal year, from the solicitation disclosure requirements reproduced on page 5.
Our organization solicits contributions in the following county. (If your organization solicits in more than one county, your
organization does not qualify for this affidavit.)
Name of County:
This document MUST be signed by the chief fiscal officer. Two different officer signatures required.
_______________________________________________
__________________________________________________
Signature of President or Authorized Officer
Date
Signature of Chief Fiscal Officer
Date
SUBSCRIBED AND SWORN TO BEFORE ME
SUBSCRIBED AND SWORN TO BEFORE ME
THIS ________ DAY OF _________________, ________
THIS ________ DAY OF _________________, ___________
________________________________________________
___________________________________________________
(Notary Public)
(Notary Public)
My Commission Expires: ___________________________
My Commission Expires: ______________________________
CO WI SUPPLEMENT TO FINANCIAL REPORT
Page 4 of 5
DFI/LFS/1943 (R 4/2014)
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