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

CRI-200 Short-Form Registration Verification Financial Statement

Note: If the financial value of a line item = 0, place a zero in the space provided.

Please report all figures as GROSS, not NET.

Full legal name and street address of the organization

Full legal name:__________________________________________________________________________________________

Fiscal year-end being reported: _____/_____/_____ Federal ID Number (EIN) __________________

month day year

Mailing address:

_______________________________________________________________________________________________________

Mailing Address

P.O. Box Number or Suite

C ity State ZIP code

Street address of the registering organization: __________________________________________________________________

Street Address

C ity State

ZIP Code

New Jersey Charities Registration number: CH _______________ -00 Telephone number: _________________________

(include area code)

In lieu of completing the lower portion of this page, please find a copy of the I.R.S. 990 form filed for the fiscal year-end

being reported, attach to this Registration/Verification Statement.

R evenue

L ine A1. Contributions & Donations: Includes but is not limited to individual and corporate contributions, donations, legacies,

bequests and gross receipts from fundraising:

A1a. Direct Public Support …………………………………........................

_ _________________

A1b. Indirect Public Support (including donations from other charities) .....

__________________

A1c. Gross Contributions (add lines 1a and 1b) ...........................................

__________________

Line A2. Government Grants (add lines 1a and 1b) ...…..............................................

__________________

L ine A3. Other Income

A3a. Membership dues and assessments ……………………........................

_ _________________

A3b. Interest and dividends ............................................................................

_ _________________

A3c. Program service revenue ………………………………........................

_ _________________

A3d. Gain from sale of assets .........................................................................

_ _________________

A3e. Other income (please specify on a separate statement): ........................

__________________

A3f. Donations from founder(s) of private foundation .................................

__________________

A3g. Total other income..................................................................................

_ _________________

Line A4. Total Gross Revenue (add lines A1c, A2 and A3g)….....................................

__________________

B. Expenses

L ine B1. Program …………………………………................... . ...................................

_ _________________

Line B2. Management, office and general expenses………………...............................

__________________

Line B3. Fund-raising expenses…………………………….................... . .....................

_ _________________

Line B4. Payments to state/national affiliates (if applicable)………………….............

__________________

Line B5. Total Expenses (add lines B1, B2, B3 and B4)………...................................

__________________

C. Excess or Deficit

L ine C1. Excess or deficit for the year-end noted above (subtract line B5 from A4):....

__________________

Please Note: The amount of Gross Contributions ( line A1c on this form) determines the registration fee which must be paid and the

form which should be used. July 2006 revisions to the Charities Registration Act now require all charities to pay a registration fee,

including charities whose Gross Contributions are less than $10,000. Further information for charity registrants may be found on our

Web site:

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Form Cri-200 - Short-Form Registration/verification Statement Page 4

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