Form Ct-12 - Charitable Activities Section - 2016

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Charitable Activities Section
CT-12
You can now file reports and
Form
Oregon Department of Justice
pay by credit card using our
For Oregon Charities
online form at
100 SW Market Street
VOICE
(971) 673-1880
For Accounting Periods Beginning in:
https://justice.oregon.gov/
Portland, OR 97201-5702
FAX
(971) 673-1882
2016
paymentportal/Account/Login
Email: charitable.activities@doj.state.or.us
Website:
Section I.
General Information
1.
Cross Through Incorrect Items and Correct Here:
(See instructions for change of name or accounting period.)
Registration #:
Organization Name:
Address:
City, State, Zip:
Phone:
Fax:
Amended
Email:
Report?
Period Beginning:
/
/
Period Ending:
/
/
Did a certified public accountant audit your financial records? - If yes, attach a copy of the auditor’s report, financial statements,
2.
Yes
No
accompanying notes, schedules, or other documents supplementing the report or financial statements.
3.
Is the organization a party to a contract involving person-to-person, advertising, vending machine or telephone fund-raising in
Yes
No
Oregon?
If yes, write the name of the fund-raising firm(s) who conducts the campaign(s):_____________________________________
4.
Has the organization or any of its officers, directors, trustees, or key employees ever signed a voluntary agreement with any
government agency, such as a state attorney general, secretary of state, or local district attorney, or been a party to legal action
Yes
No
in any court or administrative agency regarding charitable solicitation, administration, management, or fiduciary practices? If
yes, attach explanation of each such agreement or action. See instructions.
5.
During this reporting period, did the organization amend its articles of incorporation, bylaws, or trust documents, OR did the
organization receive a determination letter from the Internal Revenue Service relating to its tax-exempt status? If yes, attach a
Yes
No
copy of the amended document or letter.
Yes
No
6.
Is the organization ceasing operations and is this the final report? (If yes, see instructions on how to close your registration.)
Provide contact information for the person responsible for retaining the organization’s records.
7.
Name
Position
Phone
Mailing Address & Email Address
List of Officers, Directors, Trustees and Key Employees – List each person who held one of these positions at any time during the year even if they did
8.
not receive compensation. Attach additional sheets if necessary. If an attached IRS form includes substantially the same compensation information,
the phrase “See IRS Form” may be entered in lieu of completing that section. (Oregon law requires a minimum of three directors for nonprofit
corporations.)
(A) Name, mailing address, daytime phone number
(B) Title &
(C)
and email address
average weekly
Compensation
hours devoted to
(enter $0 if
position
position unpaid)
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(_ _ _)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Email:
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(_ _ _)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Email:
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(_ _ _)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Email:

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