Form Chr-1 - West Virginia Registration Statement Of Charitable Organization - 2017
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4WEST VIRGINIA REGISTRATION STATEMENT
1
OF CHARITABLE ORGANIZATION
Date
Registration Type:
Renewal
Final
New
1.
Official Name of Organization
2.
Street Address
City
County
Zip Code
State
3.
Mailing Address
City
County
Zip Code
State
4.
Phone
Fax
Email
5.
Principal West Virginia address
if different from above
6.
Designated contact person
Phone:
Purpose of the organization:
7.
8.
Name, address and respon-
sible person of each chapter,
branch or affiliate in the State,
if any:
Check one:
9.
Are the above chapters, branches or affiliates included
in parent organization’s registration?
Yes
No
List all names under which applicant
10.
intends to use if different from
official name, if any:
11.
State the purposes for which
will be used:
contributions
Place and date the organization was
12.
legally established:
(Place)
(Date)
Is your organization an endowment-based
13a.
Yes
organization?
No
Unincorporated
13b.
The form of the organization
Corporation
Foundation
Association
(check or complete as applicable)
Trust
Other
14a. Has the organization been determined to
Yes
Type of IRS classification: 501(c)
be tax-exempt by the Internal Revenue
No
Service?
Revised 01/17
Issued by the Office of the Secretary of State
Form CHR-1
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