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Form Pcureg-01 - Annual Charity Registration Application And Instructions - Department Of Consumer Protection

Mail Registration Application to:

STATE OF CONNECTICUT

Public Charities

DEPARTMENT OF CONSUMER PROTECTION

ANNUAL CHARITY REGISTRATION APPLICATION AND INSTRUCTIONS

165 Capitol Avenue

FORM PCUREG-01, REV OCT 10 4 PAGES

Hartford, CT 06106-1630

TELEPHONE: (860) 713-6170

EMAIL registration questions to CTCHARITYHELP@CT.GOV

STATE OF CONNECTICUT - Charitable Organization Registration Application

This is a four page application, including instructions. Please read the instructions on pages 3 and 4 before completion.

All organizations must provide an email address. Email Address : _____________________@________

Enter the organization’s Connecticut Registration Number if previously registered.

Organization’s Legal Name:

In Care of:

Mailing Address:

City:

State:

Zip Code:

Physical Address (if different):

City

State:

Zip Code:

Tel. Number: (

)

Web Site URL: WWW

Federal Employer Identification Number (FEIN):

Exempt under Internal Revenue Code Section 501(c)( ) (insert code section if exempt)

Enter the date your last fiscal year ended or the date your first fiscal year will end(

mm/dd/yy)

Names, other than the names given above, under which funds will be solicited (attach a sheet if needed).

Is the organization incorporated?

Yes

No If YES, enter the State of incorporation:

Questions 6a, 6b, 6c and 6d relate to your organization’s most recently completed year end. If your answer to

any question is YES, attach a detailed explanation for that question.

Has there been any change in the organization’s tax status with the IRS?

Yes

Has there been a significant change in the purpose of the organization?

Yes

Has the organization’s right to solicit funds been denied, suspended, revoked, or

enjoined by any state agency or by any court, or are proceedings pending?

Yes

Has the organization entered into a voluntary agreement of compliance with any

government agency?

Yes

Does the organization plan to use an outside fund-raising counsel or paid solicitor within the

registration period? If YES, attach a separate sheet with its name and address.

Yes

Has the organization used an outside fund-raising counsel or paid solicitor during its

most recently completed year? If YES, attach a sheet with its name and address.

Yes

If this application is for an initial registration, has the organization solicited contributions in Connecticut

during any year prior to the year reported with this application?

Not an initial application

Yes

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Form Pcureg-01 - Annual Charity Registration Application And Instructions - Department Of Consumer Protection

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