Form Ss - 6039 - New Charitable Organization Quarterly Financial Report (Unaudited)
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State of Tennessee
W A R N I N G : F a l s e o r m i s l e a d i n g s t a t e m e n t s subject to maximum
$5,000 penalty. T.C.A. §48-101-514
Date Received
NEW CHARITABLE ORGANIZATION
Department of State
QUARTERLY FINANCIAL REPORT
(Unaudited)
Division of Charitable Solicitations & Gaming
William R. Snodgrass Tennessee Tower
th
312 Eighth Avenue North, 8
Floor
Nashville, TN 37243
(615) 741-2555 / (615) 253-5173 - fax
___________________________________________________________________
NSTRUCTIONS: T.C.A. § 48-101-504(c) requires all new charitable organizations, subject to T.C.A. § 48-
I
101-501 et seq., to file quarterly financial reports with the Secretary of State during the first fiscal year of
operation. These reports are due within thirty (30) days after the end of each quarter. Each report must be
signed and notarized by two authorized officers.
If your first fiscal year began prior to registering with this office, the quarterly reports for periods ending more
than thirty (30) days prior to registering are due upon making application.
_____________________________________________________________________________________
1. Organization Name: ____________________________________________________________
2. Registration Number: _________________________
st
nd
3. Financial Period
:
1
Quarter
2
Quarter
rd
th
3
Quarter
4
Quarter
_______ _______ _______
TO _______ _______ _______
Month
Day
Year
Month
Day
Year
_____________________________________________________________________________________
I. REVENUE
Gross Contributions:
$ ______________________
Other Revenue:
$ ______________________
0
Total Revenue
$ ______________________
II. EXPENSES
Program Services:
$ _____________________
Fundraising:
$ _____________________
Administrative:
$ _____________________
Other (Attach Schedule)
$ _____________________
0
Total Expenses
$ _____________________
_____________________________________________________________________________________
Number of continuation pages attached: _________________
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