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Form C100 - Georgia Charitable Solicitations Act Charitable Organization Registration Page 2

APPLICANT’S NAME:

To amend, circle numbers being amended and file with a completed execution page (C100 page 1)

5. Status of registration in other jurisdictions

Enter “1” for pending registrations, “2” if already registered, and leave blank if not registered.

ORGANIZATION

6. Fiscal Year Ends on (Month/Day):

Date of Formation:

Place of Filing:

Applicant is a:

Corporation

Proprietorship

Partnership

Limited Liability Company

Other:

8. If FOREIGN Corporation, date qualified to transact business in Georgia:

The following financial information must accompany the application in order for

registration to become effective:

An IRS Form 990 or 990 E-Z dated within one year of filing AND one of the following types

of financial statements dated within one year of filing:

a. Organizations that received or collected more than $1,000,000 in the preceding fiscal year

must submit a financial statement certified by an independent certified public accountant.

b. Organizations that received or collected more than $500,000 but less than $1,000,000 must

submit a financial statement reviewed by an independent certified public accountant

c. Organizations that received or collected less than $500,000 must submit a financial

statement. The financial statement does not have to be reviewed or certified.

d. If no funds have been received or collected, attach a signed statement to that effect.

10. State the general purpose for which the charitable organization is organized (attach additional sheets if necessary):

SOLICITATION INFORMATION

11. Specify the purpose or object for which funds solicited will be used (attach additional sheets if necessary):

12. Specify the method and period of time of solicitation:

Form C100 Rev. Sept 2010

Page 2

Form C100 - Georgia Charitable Solicitations Act Charitable Organization Registration Page 2