STATE OF MINNESOTA
Supplement To Unified Registration Statement
F
C
O
I
R
& A
R
OR
HARITABLE
RGANIZATION
NITIAL
EGISTRATION
NNUAL
EPORTING
A
G
L
S
Annual Reporting
Initial Registration
TTORNEY
ENERAL
ORI
WANSON
S
1200, B
T
UITE
REMER
OWER
FEDERAL EIN NUMBER:
445 M
S
INNESOTA
TREET
S
. P
, MN 55101-2130
T
AUL
(651) 757-1311
FOR YEAR ENDING:
(651) 296-1410 (TTY)
S
O
: R
I
I
R
& A
R
ECTION
NE
EQUIRED
NFORMATION FOR
NITIAL
EGISTRATION
NNUAL
EPORTING
All organizations MUST complete questions 1 & 2.
1.
Legal Name of Organization: __________________________________________________________
2.
Complete the following for the most recent twelve-month accounting year. While this information
should reflect the financials on the IRS Form 990, this section is required to be completed even if an
IRS Form 990 is attached.
Before completing this section, please refer to the Annual Report
Instructions.
INCOME
For Year Ending: _____________________
Contributions from the public
$__________________
Government Grants
$__________________
Other revenue
$__________________
TOTAL REVENUE
$__________________
EXPENSES
Amount spent for program or charitable purposes
$__________________
Management/general expense
$__________________
Fund-raising expense
$__________________
$__________________
TOTAL EXPENSES
EXCESS or DEFICIT
$_______________
TOTAL Assets
$_______________
TOTAL Liabilities
$_______________
END OF YEAR FUND BALANCE/NET WORTH (Assets minus Liabilities) $__________________
S
T
: R
I
R
O
ECTION
WO
EQUIRED FOR
NITIAL
EGISTRATION
NLY
1.
Please attach a copy of the organization’s IRS determination letter and formation documents (i.e.
Articles of Incorporation).
2.
Attach a list of the organization’s officers, directors, trustees, and chief executive officer, including
their titles, addresses, and total annual compensation paid to each.
Attached
For Office Use Only:
ARF
$25
$50
$75
990
EZ
PF
FES
SIG
BD
SAL
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