Form Chr-1 - Registration Statement Of Charitable Organization Page 3

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3
17.
Is the organization authorized to solicit by any other state?
Yes
No
If yes, please list four other states:
1.
2.
3.
4.
18.
Has the organization ever been enjoined by any court, or otherwise
Yes
No
prevented by any governmental body, from soliciting contributions in
any state? (If yes, explain in detail on separate sheet)
19.
Give names and
a.
Custodian of
addresses for the
financial records:
chief person
responsible for
the following
b.
Custodian of
duties:
contributions:
c.
Person(s) making
final distribution:
Amount proposed to be
in West Virginia (estimate):
20.
$
Actual amount of funds
in West Virginia last fiscal year
21.
Amount disbursed for program services in West Virginia during
22.
$
the period covered by this report: (Please estimate -- if left blank, a
$0 will be entered)
$
Amount disbursed for program services outside West Virginia
23.
during the same period:
$
24.
The license number of the raffle, bingo or other state
permit used for fund-raising if any:
Computation of Fund-Raising Percentage
25.
$
$
=
%
÷
Fund-Raising Expenses
Income Derived From Fund-Raising
Percentage
26.
How much did organization receive from government grants
$
or private foundations during last year?
Revised 1 /
Issued by the Secretary of State, State Capitol, Charleston, WV 25305
FORM CHR-1

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