Form Char410-R - Charities Re-Registration Statement - 2002

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CHAR410-R
STATE OF NEW YORK
CHARITIES RE-REGISTRATION STATEMENT
DEPARTMENT OF LAW
CHARITIES BUREAU - REGISTRATION SECTION
Fo r Office U se Only
120 BROADWAY
Registration No
NEW YOR K, NY 10271
7-A
EPTL
Dual
INSTRUCTIONS - TYPE or PRINT in ink the answers to all items applicable to the registrant.
1.
ORGAN IZATION’S NAME:
ADDRESSES
Street
City
State
Zip
2. Principal A ddress:
3. M ailing A ddress:
(if different from above)
4. W her e Bo oks/ Re cord s Ar e K ept:
(if different from above)
5. Principal N ew Y ork State A ddress:
(if different from above)
6.
LIS T A LL NA M ES U ND ER W HI CH OR GA NIZ AT IO N S OL ICIT S C ON TR IBU TIO NS (INC LU DIN G G RA NT S):
7.
DA YT IM E P HO NE NO : (
)
FA X N O: (
)
E-MAIL ADD RESS
8.
DATE FISCAL YEAR EN DS: Month
Day
9.
DA TE AN D S TA TE IN W HI CH INC OR PO RA TE D O R F OR M ED :
Date :
State:
10. DA TE BE GA N (A ) DO ING BU SIN ESS IN N Y:
(B) SO LIC ITIN G C ON TR IBU TIO NS IN N Y:
11. DA TE BE GA N M AIN TA ININ G A SSE TS I N N Y:
12. HAS THE OR GANIZATION PREVIOUSLY BEEN REGISTERED WITH THE N EW YO RK STATE ATTORN EY
G E N E R A L A N D / O R N E W Y O R K S TA T E D EP A R T M E N T O F S T A TE ’S O F F IC E O F C H A R IT IE S R EG I ST R A T IO N ? . . .
YES
N O
If yes:
a.
Re gistration N um ber (s):
b.
Name, if not the same as in Num ber 1 above:
13. LIST P R O F E SS IO N A L F U N D R AI SE R S (P F R ), F U N D R A IS IN G C O U N S E L ( FR C ) A N D C O M M E R C I A L C O - VE N T U R ER S (C C V ) W H O H A V E
A G R E E D TO A C T O N B E H A LF O F T H E O R G A N IZ A T IO N :
F R C , P F R , C C V
ADDR ESS
C O N T RA C T PE R IO D
14. INTERNAL R EVENUE SERVICE AN D TAX EX EMPT STATUS Q UESTIONS:
A . Fed eral E mp loyer Id entification Nu mb er (E IN):
B.
Has the organization been granted tax exempt status by the IRS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
yes
no
1.
If yes:
a.
Date granted
b.
Ap plicable In terna l Rev enu e C ode p rovision : 501(c)(
)
2.
If no, has the org anization applied for tax e xem pt status? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
yes
no
a.
If yes:
i.
Date applied
ii.
Has tax exemption ever been denied? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
yes
no
(a) If yes:
(i)
Name of Agency
(ii) Date of Denial
15. NTEE CODE

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