Washington State Unified Registration Statement Addendum - Washington Secretary Of State - 2009
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STAPLE
Charities Program • 801 Capitol Way South • PO Box 40234 • Olympia, WA 98504-0234
Phone: 360-725-0378 • Fax: 360-664-4250 • E-mail:
charities@sos.wa.gov
Web Address:
WASHINGTON STATE UNIFIED REGISTRATION STATEMENT ADDENDUM
Check here to request EXPEDITED MAIL SERVICE (optional). If checked, please enclose an additional $20 fee.
Make fees payable to “State of Washington”
Please complete entire form or write “n/a” if not applicable. Incomplete forms will not be accepted.
All documents must be typewritten or printed legibly in ink. DO NOT staple or bind form or attachments.
SECTION 1 - ORGANIZATION INFORMATION
Organization’s Full Legal Name:
WA State Registration Number:
UBI
Number
:
(Unified Business Identifier)
(if located in WA)
SPECIFIC BENEFICIARIES
In the event of dissolution, will assets be distributed to a specific beneficiary whom the organization supports?
Yes
No
If yes, attach a list containing the names and addresses of specific, named beneficiaries.
SECTION 2 - FINANCIAL, ADMINISTRATIVE & FUNDRAISING INFORMATION
THE NEXT TWO QUESTIONS PERTAIN TO FINANCIAL INFORMATION PROVIDED IN SOLICITATION REPORT
Did the organization solicit or collect contributions in Washington during the fiscal/accounting year reported below? (check one)
Yes
No
If no, please check reason:
New organization
No activity in Washington State
Other: ___________________________
(describe)
If new organization, please provide the fiscal/accounting year end date of the first year during which solicitations will be conducted in
WA and proceed to Three Highest Paid Officers Or Employees Of The Organization section: _____/_____/_____ (REQUIRED)
month
day
year
Did/will the organization submit a Federal tax return to the Internal Revenue Service for the fiscal/accounting year reported below?
(check one)
Yes
No
If yes, check type of return:
Form 990
Form 990 EZ
Form 990PF
990-T
1120
Other: ______________
(describe)
If no, check reason:
Church/church-affiliated
Government-affiliated
Covered by group return
Annual gross receipts
less than $25,000
Organization not tax-exempt
Other
: _________________________________________
(describe)
REQUIRED ATTACHMENT
If the organization has/will file an IRS Form 990, 990EZ or 990PF with the Internal Revenue Service for the fiscal/accounting
year reported below…a complete copy of the tax return MUST be provided with this addendum. Be sure to include Schedule A and all
attachments except contributor lists/Schedule B. Do not enclose the organization’s bank statements or annual report. DO NOT staple or
bind Form 990, 990EZ or 990PF, Schedule A, or their attachments.
NOTE:
If the organization’s tax return for the fiscal/accounting year reported below has not yet been completed, please contact our
office for instructions. DO NOT submit the URS, URS Addendum or filing fee without a copy of the Form 990, 990EZ or 990PF.
SOLICITATION REPORT
Please supply fiscal/accounting beginning/ending dates and complete line items 1 - 8 (REQUIRED)
Suggested guidelines for completing the Solicitation Report using the organization’s federal tax return can be obtained at
or by contacting the Charities Program directly.
Fiscal/accounting year begin date:
Fiscal/accounting year end date:
(Mo/Day/Year)
(Mo/Day/Year)
URS Addendum/Rev 11/09
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