Form Char410 - Charities Registration Statement - 2002
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1
2CHAR410
STATE OF NEW YORK
CHARITIES REGISTRATION STATEMENT
DEPARTMENT OF LAW
CHARITIES BUREAU - REGISTRATION SECTION
Fo r Office U se Only
120 BROADWAY
Registration No
NEW YOR K, NY 10271
7-A
EPTL
Dual
INSTRUCTIONS - TYPE or PRINT in ink the answers to all items applicable to the registrant. This form must be filed with the
Department of Law (Attorney General) if it is a New York charitable organization or holds property or does business in New York for
charitable purposes. In addition, any organization, wherever it is located, that solicits contributions in New York and receives in excess
of $25,000 or pays anyone other than its employees to raise funds must complete this form.
1.
ORGAN IZATION’S NAME:
ADDRESSES
Street
City
State
Zip
2. Principal A ddress:
3. M ailing A ddress:
(if different from above)
4. W her e Bo oks/ Re cord s Ar e K ept:
(if different from above)
5. Principal N ew Y ork State A ddress:
(if different from above)
6.
LIS T A LL NA M ES U ND ER W HI CH OR GA NIZ AT IO N S OL ICIT S C ON TR IBU TIO NS (INC LU DIN G G RA NT S):
7.
DA YT IM E P HO NE NO : (
)
FA X N O: (
)
E-MAIL ADD RESS
8.
DATE FISCAL YEAR EN DS: Month
Day
9.
DA TE AN D S TA TE IN W HI CH INC OR PO RA TE D O R F OR M ED :
Date :
State:
10. DA TE BE GA N (A ) DO ING BU SIN ESS IN N Y:
(B) SO LIC ITIN G C ON TR IBU TIO NS IN N Y:
11. DA TE BE GA N M AIN TA ININ G A SSE TS I N N Y:
12. HAS THE OR GANIZATION PREVIOUSLY BEEN REGISTERED WITH THE N EW YO RK STATE ATTORN EY
G E N E R A L A N D / O R N E W Y O R K S TA T E D EP A R T M E N T O F S T A TE ’S O F F IC E O F C H A R IT IE S R EG I ST R A T IO N ? . . .
YES
N O
If yes:
a.
Re gistration N um ber (s):
b.
Name, if not the same as in Num ber 1 above:
13. LIST PROFESSIONAL FUND RAISERS (PFR), FUND RAISING COUNSEL ( FR C ) A N D C O M M E R C I A L C O - VE N T U R ER S (C C V ) W H O H A V E
A G R E E D TO A C T O N B E H A LF O F T H E O R G A N IZ A T IO N :
F R C , P F R , C C V
ADDR ESS
C O N T RA C T PE R IO D
14. INTERNAL R EVENUE SERVICE AN D TAX EX EMPT STATUS Q UESTIONS:
A . Fed eral E mp loyer Id entification Nu mb er (E IN):
B.
Has the organization been granted tax exempt status by the IRS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
yes
no
1.
If yes:
a.
Date granted
b.
Ap plicable In terna l Rev enu e C ode p rovision : 501(c)(
)
2.
If no, has the org anization applied for tax e xem pt status? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
yes
no
a.
If yes:
i.
Date applied
ii.
Has tax exemption ever been denied? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
yes
no
(a) If yes:
(i)
Name of Agency
(ii) Date of Denial
15. NTEE CODE
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