Form Ss-6007 - Application To Renew Registration Of A Charitable Organization
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1
2State of Tennessee
W A R N I N G : F a l s e o r m i s l e a d i n g s t a t e m e n t s
Subject to maximum $5,000 penalty. T.C.A. §48-101-514
APPLICATION TO RENEW REGISTRATION
Department of State
OF A CHARITABLE ORGANIZATION
Division of Charitable Solicitations
312 Eighth Avenue North
th
8
Floor, William R. Snodgrass Tower
Nashville, TN 37243
(615) 741-2555
INSTRUCTIONS: Please type or print all items on this form which are applicable to your
OFFICE USE ONLY
organization. If you are unable to answer in the space provided, you may attach additional sheets.
Reg. No.
Date Rec'd.
Indicate that an item does not apply by placing N/A by its number. A nonrefundable registration fee
must accompany this application. The amount of the filing fee is as follows:
Organization’s
Annual
Fee Pd.
Gross Revenue
Filing Fee
$0-$48,999.99 ……………………………………. $100.00
$49,000.00-$99,999.99 ………………………...… $150.00
$100,000.00-$249,999.99 ………………………... $200.00
Rec. No.
$250,000.00-$499,999.99 ………………………... $250.00
$500,000.00-ABOVE ……………………………. $300.00
See REVERSE side for additional instructions.
1.
Name of organization:_______________________________________________________________FEIN_________________
2.
Do you solicit contributions under any other name(s)? Yes
No
If yes, indicate below:
_______________________________________________________________________________________________________
3.
Principal Office Address:
(Street)
(City)
(State)
(Zip)
A. If organization does not maintain an office, name and address of person having custody of financial records:
(Street)
(City)
(State)
(Zip)
B. Mailing Address:
(Street)
(City)
(State)
(Zip)
4.
Telephone Number: (
)_____________
Fax Number: (
)_____________
Email Address:________________________
5.
Do you have other offices in Tennessee? Yes
No
If yes, indicate below:
_______________________________________________________________________________________________________
6.
Have you added any Chapters, Branches or Affiliates in Tennessee since your last registration? Yes
No
If yes; list name
and address: ________________________________________________________________________________________
_______________________________________________________________________________________________________
Are you registering and reporting the financial activities of these organizations? Yes
No
7.
Has your charter or by-laws been amended since your last registration? Yes
No . If yes, attach amendment(s).
8.
Has your tax exempt status been revoked by the Internal Revenue Service since your last registration? Yes
No
If status has been revoked, attach a copy of letter of revocation.
9.
Has your fiscal year changed since your last registration? Yes
No . If yes, your new fiscal year: ____________________
10. Attach a list of all states where you are currently registered.
11. Have you been enjoined by any court from soliciting contributions since your last registration? Yes
No
If yes, attach
detailed explanation
12. Attach a list of the name, title, address and phone number of each officer, director, trustee and principal salaried officer.
13. Has any officer, director, manager, operator or principal been the subject of an injunction, judgment or administrative order or
been convicted of a felony?
Yes
No
If yes, attach detailed explanation.
14. Describe the purpose of the organization: ______________________________________________________________________
_______________________________________________________________________________________________________
15. Indicate method(s) by which solicitations will be made during this registration period: Personal contact
Mail
Telephone
Radio/TV
Volunteers
Professional Solicitor
Fund Raising Counsel
Vendor
Internet
Webpage address:______________________________
Other
__________________________________________
A. List the name(s) and address(es) of persons hired by organization to assist in solicitation activities:
(Name)
(Street)
(City)
(State)
(Zip)
(Name)
(Street)
(City)
(State)
(Zip)
B. Attach a true copy of any contract with persons named above.
16. List the name and address of individual(s) who have final responsibility for the custody of contributions are:
(Name)
(Street)
(City)
(State)
(Zip)
17. List the name and address of individual(s) who have responsibility for the final distribution of contributions are:
(Name)
(Street)
(City)
(State)
(Zip)
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