Sample Registration Of Charitable Organizations Form - Tennessee Secretary Of State Page 2
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2SAMPLE
Division of Charitable Solicitations and Gaming
Tre Hargett, Secretary of State
WA R N IN G: F alse o r misleadin g stat ement s Subject
to maximum $5,000 civil penalty. T.C.A. §48-101-514
SUMMARY OF FINANCIAL ACTIVITIES
State of Tennessee
312 Rosa L. Parks Avenue, 8th Floor
OF A CHARITABLE ORGANIZATION
Nashville, Tennessee 37243
615-741-2555
Fax: 615-253-5173
: Complete this form with financial information from the most recently completed accounting
INSTRUCTIONS
year. The form must be signed by two (2) authorized officers, one of whom shall be the Chief Fiscal Officer.
Please see the sample Summary of Financial Activities for the corresponding lines on page 9 and 10 of the
IRS Form 990.
Name of Organization:
Address:
City:
State:
Zip Code:
Federal ID:
State ID:
Telephone:
Accounting Year End:
Has your accounting year changed? Yes
No
A. Gross Revenue
(From page 9 of 990)
1.
Public Contributions ..................
..................... $ _______________________________
(1 h minus 1 e)
2.
Government Grants .................
.....................................$ _______________________________
(1e)
3.
Program Service Revenue.........
.....................................$ _______________________________
(2g)
4.
Special Events and Activities .....
.....................................$ _______________________________
(8a)
5.
Gross Sales of Inventory ...........
....................................$ _______________________________
(10a)
6.
Other Revenue ......
(3+4+5+6a..+/- 7d+9a+11e)
................... $ _______________________________
7.
Total Revenue ...........
........ $ _______________________________
[Add Line 1 Through Line 6 above]
B. Expenses
(From page 9 and 10 of 990)
8.
Total Program Expenses............
...................... $ _______________________________
(25, Column b)
9.
Direct Expenses from Special Events............
$ _______________________________
(8b)
....................
10.
Cost of Goods Sold.........................
...............................$ _______________________________
(10b)
11.
Management and General Expenses .....
$ _______________________________
(25, Column c)
..........
12.
Fund Raising Expenses .............
...................... $ _______________________________
(25, Column d)
13.
Other Expenses ......................
.................................$ _______________________________
(6b + 9b)
Total Expenses .........
14.
......... $ _______________________________
[add line 8 through line 13 above]
15.
Excess / Deficit for the year ....
] .... $ _______________________________
[line 7 minus line 14 above
C. Changes in Net Assets or Fund balances
(990, Page 1)
16.
Net assets / fund balances at beginning of year ......
....... $ _______________________________
(22)
17.
Other changes in net assets or fund balances
(Sch. D, Part XI or p.12, line 5)
.........................................................$ ___________________________________
18.
Net assets / fund balances
........... $ _______________________________
[add line 15 through line 17]
19.
Total Assets.............................
........................................$ _______________________________
(20)
20.
Total Liabilities ........................
........................................$ _______________________________
(21)
21.
Net assets / fund balances
.................... $ _______________________________
[line 19 minus line 20]
D. Accounting Method Used:
CASH:
ACCRUAL:
OTHER:
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