Form Char410 - Charities Registration Statement
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1
2
3State of New York
CHAR410
Office of the Attorney General
For Office Use Only:
Charities Bureau
No. _____________________
___ 7-A ___ EPTL ___ DUAL
120 Broadway, New York, NY 10271
CHARITIES REGISTRATION STATEMENT
INSTRUCTIONS - TYPE or PRINT in ink the answers to all items applicable to the registrant. This form must be filed with the Office of the Attorney General if it is
a New York charitable organization, or holds property or does business in New York for charitable purposes. In addition, any organization, wherever it is located,
that solicits contributions in New York and receives in excess of $25,000 or pays anyone other than its employees to raise funds must complete this form.
1. ORGANIZATION'S NAME:
__________________________________________________________________________________________________________
2. PRINCIPAL STREET ADDRESS:
___________________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
3. MAILING ADDRESS (if different from above):
___________________________________________________________________________________________________________
4. PRINCIPAL NEW YORK STATE ADDRESS (if different from above):
___________________________________________________________________________________________________________
5. ADDRESS WHERE BOOKS/RECORDS ARE KEPT:
___________________________________________________________________________________________________________
6. LIST ALL NAMES UNDER WHICH ORGANIZATION SOLICITS CONTRIBUTIONS (INCLUDING GRANTS):
___________________________________________________________________________________________________________
7. DAYTIME PHONE NUMBER: (
)
FAX NUMBER: (
)
8. DATE FISCAL YEAR ENDS: Month ____________ Day ____________
9. DATE AND STATE IN WHICH INCORPORATED OR FORMED: Date:
State:
10. DATE BEGAN DOING BUSINESS IN NEW YORK:__________________________________
11. DATE BEGAN MAINTAINING ASSETS IN NEW YORK:_______________________________
12. HAS THE ORGANIZATION PREVIOUSLY BEEN REGISTERED WITH NEW YORK STATE OFFICE OF THE
ATTORNEY GENERAL AND/OR CHARITIES SECTION OF DEPARTMENT OF STATE?
____ YES ____ NO IF YES, REGISTRATION NUMBER(S):______________________________________
Name, if not the same as in Number 1 above:_____________________________________________________
13. LIST PROFESSIONAL FUND RAISERS (PFR), FUND RAISING COUNSEL (FRC) AND COMMERCIAL CO-
VENTURERS (CCV) WHO HAVE AGREED TO ACT ON BEHALF OF THE ORGANIZATION:
FRC, PFR, CCV
ADDRESS
CONTRACT PERIOD
______________________ _______________________________________________ _____________________
______________________ _______________________________________________ _____________________
______________________ _______________________________________________ _____________________
14. HAS THE ORGANIZATION APPLIED FOR OR BEEN GRANTED TAX EXEMPT STATUS BY THE IRS?
_____ yes ___ no If yes, enter the date of application or the Federal ID Number:
(date applied)_____________________(date granted)_________________________(fed. ID #)__________________
15. HAS TAX EXEMPTION EVER BEEN DENIED? _____ Yes ____ No
If yes, name of agency and date of denial _______________________________
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