Form Cri-200 - Short-Form Registration/verification Statement (Page 3 of 4) in pdf

12. If the answer to 11a, 11b or 11c is “Yes,” please attach to this registration a statement that provides the details of the action,

together with the reason(s) for that denial, suspension, revocation, injunction, compliance agreement etc., including the state or

jurisdiction involved, the dates and full copies of all related documents.

Indicate the attachment of documents to this Registration/Verification Statement by checking this box: £

13. Is the organization currently I.R.S. tax-exempt? £ Yes £ No

If “Yes,” under which section of the code?___________________________________________

14. Has the organization’s tax-exempt status been revoked, changed, or refused by the I.R.S.? £ Yes £ No

If “Yes,” please attach to this registration a statement providing an explanation, including all of the facts, dates, and all letters and

notices received from the I.R.S.

15. Has the organization used an independent paid fund-raiser, fund-raising counsel or commercial co-venturer? £ Yes £ No

If “Yes,” for what purpose(s) are funds being raised? ____________________________________________________________

15a. If the answer to question 15 is “Yes,” write in or provide a separate listing of the name(s) of all independent paid fund-raiser(s),

fund-raising counsel and/or commercial co-venturer(s):__________________________________________________________

16. Provide on a separate sheet of paper the name, title, street address, telephone number and salary of each officer, director and

trustee, and the five most-highly compensated employees in the organization.

Indicate the attachment of documents to this Registration/Verification Statement by checking this box:

16a. Has any person listed in the response to question 16 been adjudged liable in any administrative or civil action, or been convicted

in a criminal action involving theft, fraud or deceptive business practices? £ Yes £ No

If the response is “Yes,” please provide all of the details on a separate sheet and also attach to this registration a copy of the order,

judgment or other document(s) indicating final disposition of the matter.

Please note: For the purpose of question 16a, a plea of guilty, non vult, nolo contendere or any similar disposition of the

alleged activity shall be deemed a conviction. A judgment of liability in an administrative or civil action would include a finding

or admission that the individual engaged in an unlawful practice relating to the solicitation of contributions or the administration

of charitable assets.

We understand that this registration is being issued at the discretion of the Division of Consumer Affairs and agree that employees of the

Division may inspect the records in the possession of this organization in order to ascertain compliance with the statute and all pertinent

regulations. We also understand that we may be required to provide additional information if requested.

We hereby certify that the above information and the attached financial schedule(s) and statement(s) are true. We are aware that if any

of the above statements are willfully false, we are subject to punishment.

Signature____________________________ Name______________________________ Title ______________ Date ____________

This form must be signed by two (2) authorized officers of the organization, including the chief financial officer.

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Form Cri-200 - Short-Form Registration/verification Statement Page 3