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13. Does the charitable organization have a contract with a fund raising counsel or paid solicitor to solicit contributions

in Georgia?

Yes

If the answer to the above question is yes:

(a) list the name and address of the fund raising counsel or paid solicitor to be used in connection with the solicitations

in Georgia:

(b) Terms of remuneration for paid solicitor:

Yes

BACKGROUND INFORMATION

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

NOTE: (1) For the purpose of the following questions the term “executive officer” means the chief executive officer, the

president, the principal financial officer, the principal operation officer, each vice president with responsibility

involving policy-making, the treasurer or any other person performing similar functions.

(2) All YES answers to questions must be fully explained. Attach additional sheets as needed.

YES

14. In the past ten years has the applicant, executive officer, or control person been convicted of or pled guilty

or nolo contendere ( no contest) to a felony or misdemeanor which:

(a) Involves the solicitation or acceptance of charitable contributions or the making of a false oath, the making

____

of a false report, bribery, perjury, burglary, or conspiracy to commit any of the foregoing offenses?

(b) Arises out of the conduct of solicitation of contributions for a charitable organization?

____

embezzlement, fraudulent conversion, or misappropriation of funds?

____

(d) Involves murder or rape?

____

(e) Involves assault or battery if such person proposes to be engaged in counseling, advising, housing, or

sheltering individuals? Or

____

(f)

Pled guilty or nolo contendere (no contest) to any other felony offense?

____

15. Has any court:

(a)

in the past ten years enjoined the applicant or an executive officer in connection with any aspect of the

fundraising business?

(b)

ever found that the applicant or executive officer was involved in a violation of any state or federal law

regarding fundraising or any other deceptive practice?

16. Has any local, state or federal government agency:

(a) ever found the applicant or executive officer to have made a false statement or omission or been

dishonest, unfair or unethical?

(b) ever found the applicant or executive officer to have been involved in a violation of a fundraising law?

its authorization to do business denied, suspended, revoked or restricted?

(d) in the past ten years entered an order or consent order against the applicant or an executive officer in

connection with any fundraising statute or deceptive practices?

(e) ever denied, suspended, or revoked the applicant’s or an executive officer’s registration or license,

prevented it from association with a fundraising organization, or otherwise disciplined it by restricting its

activities?

(f)

ever revoked or suspended the applicant’s or an executive officer’s license as an attorney or accountant?

17. Is the applicant or executive officer now the subject of any proceeding that could result in a yes answer to

any question contained herein?

18. Does the applicant have any unsatisfied judgments or liens against it or has it filed for any type

bankruptcy?

19. Has any governmental agency, including the United States Internal Revenue Service determined that the

organization is tax exempt? If yes, attach copy of determination letter. If applicable, indicate employer

identification number here:

20. Has a tax exemption status been denied or cancelled at any time by any governmental agency or official?

Form C100 Rev. Sept 2010

Page 3

Form C100 - Georgia Charitable Solicitations Act Charitable Organization Registration Page 3

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