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DEPARTMENT OF CONSUMER PROTECTION

ANNUAL CHARITY REGISTRATION APPLICATION AND INSTRUCTIONS

FORM PCUREG-01, REV OCT 10 4 PAGES

TELEPHONE: (860) 713-6170

EMAIL registration questions to CTCHARITYHELP@CT.GOV

10.

If this application is a renewal application of an organization that let its registration expire, has the

organization solicited contributions in Connecticut during any year when its application had expired?

Not a renewal application

Yes

If question 9 or 10 is answered YES, the organization must include with this application a financial report

(IRS form and audit if required) for each such year in which the organization solicited in Connecticut, but was

not registered. Provide only the IRS form and audit for those years, no additional forms or fees.

11.

Required Attachments to this application form:

 Attach a completed IRS Form 990, 990EZ or 990PF for your most recently completed year. (See

instructions on page 3.) For initial applications only, applicants may attach the prior year IRS

form if your most recently completed year end IRS form is not complete. For any organization, an

IRS form with a year end that is more than 23 month old cannot be used because the registration

period plus any extension of time to register for that year has already passed.

 In addition to the IRS Form mentioned above, an audit may be required. Was gross revenue in

excess of $500,000 during the report year accompanying this application?

Yes

If YES, attach an audit to this form. The terms “audit” and “gross revenue” are explained in the

instructions to this form.

 Attach a list of the names, titles and addresses of officers, directors, trustees, and the principal

salaried employees of the organization. (IRS Form 990 Part VII does not provide addresses.)

 If question 6, 7, 8, 9 or 10 were answered YES, attach the required documents.

We hereby certify under penalty of false statement that we are authorized to sign this document for the organization

and that the information provided, including all attachments, is true and complete to the best of our knowledge.

Signed:

Printed Name:

Title:

Date:

**STATE LAW REQUIRES THAT TWO PERSONS SIGN THIS FORM – See instructions on signatures**

Public Act No. 05-101 provides:

In the event the department determines that the application for registration does not contain the information, fees

and documents required, the department shall notify the charitable organization, in writing, of such noncompliance

not later than ten days after the department's receipt of such application for registration. An application for

registration shall be deemed to be approved if the charitable organization is not notified of noncompliance by the

department not later than ten days after the department's receipt of the application for registration. Any such

charitable organization may request a hearing on its noncompliant status not later than seven days after receipt of

such noncompliance notice. Such hearing shall be held not later than seven days after the Department's receipt of

such request and a determination as to the organization's compliance status shall be rendered no later than three

days after such hearing.

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Form Pcureg-01 - Annual Charity Registration Application And Instructions - Department Of Consumer Protection Page 2

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