Charitable Organizations Application - 2008 (Page 2 of 3) in pdf

Names and addresses of the officers, directors, trustees, partners, senior level executive employees, as

well as those persons responsible for the day to day operations of the organization, and for a Limited

Liability Company or Limited Liability Partnership, also give the names of the members, partners and

managers: ___________________________________________________________________________

______________________________________________________________________________________________________

8. Names and addresses of any chapters, branches, affiliates or other organizations that during the

immediately preceding fiscal year shared the contributions or other revenue raised in this state.

Contributions of another organization, which are merely transferred by or through United Way or

federated fund or an incorporated community appeal, which organization is selected by the donor need not

be included:________________________________________________________________________

_____________________________________________________________________________________

9. Date and place of organization: _________________________________________________________

_____________________________________________________________________________________

10. Form of organization: _______________________________________________________________

11. Tax exempt status under Internal Revenue Code: _________________________________________

_____________________________________________________________________________________

12. A general description of all the uses for which contributions to be solicited will be used: _________

_____________________________________________________________________________________

13. Date fiscal year ends: _______________________________________________________________

14. Other states where licensed/registered: _________________________________________________

15. Has any government agency or court enjoined the applicant, its directors, members, trustees or senior

level executives from soliciting contributions? Yes ____ No ____ If yes, please describe: ____

_____________________________________________________________________________________

16. Has applicant’s license or registration been suspended or canceled by any governmental agency.

Yes ____ No ____ If yes, please describe: ______________________________________________

_____________________________________________________________________________________

17. Name and address of any professional fundraisers or fundraising counsel (and please submit a copy of

the contract(s) for services):____________________________________________________________

_____________________________________________________________________________________

18. (a) State the percentage of contributions received in the immediately preceding year which was spent

for fund raising and administration: ________________________________________________________

Charitable Organizations Application - 2008 Page 2