Form Char410 - Charities Registration Statement

16. D E S C R IB E P U R PO S E S O F O R G A N I ZA T IO N :

17. D O E S T H E O R G A N I ZA T IO N ( IN T E N D TO ) SO L I CI T C O N T R IB U T IO N S (I N C LU D I NG G R A N T S ) I N N EW Y O R K

STATE AND /OR F ROM NEW YORK STATE RESIDENT S? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES

N O

If yes, describe purposes for which contributions are/will be solicited:

18. LIST D IR E C TO R S , O FF IC E R S, T R U ST E ES A N D O F F IC IA L S I N C H A R G E O F O V ER A L L M A N A G E M E NT , IN C L UD IN G T H O SE W H O S IG N

R E P O R T S S U B M IT T E D TO T H E B O A R D :

N a me

Add ress

Title/Term

19. LIST CHAPTERS, BRANCHES AND AFFILIATES THAT SHARE IN CONTRIBUTIONS O R OTHER REVEN UE RAISED IN NEW YORK STATE:

N a me

Add ress

20. L IS T N A M E , A D D R ES S A ND A C C O U N T N U M B ER S F O R A LL A C C O U N T S O F T H E O R G A N IZ A T IO N :

B an k/ B ro ke ra ge H ou se N am e

Add ress

Ac coun t #

21. A . Is the organization authorized to solicit contributions by any other governmen tal agency? . . . . . . . . . . . . . . . . . . . . .

YES *

N O

Ha s the or ganiza tion or a ny of its officers , direc tors, exec utive p erson nel or tr ustee s ever bee n en joined by an y cou rt

from soliciting funds or been found to have engaged in unlawful practices in connection with the solicitation or

adm inistration of charitable assets? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

YES *

N O

C . Has the organization’s registration or license been suspended by an y governme nt agency? . . . . . . . . . . . . . . . . . . . . .

YES *

N O

* If YE S to A, B or C , a ttach a com plete statemen t of details.

V E R IF I CA T IO N :

W e verify, under pe na lty o f p er jur y, tha t the inf or m atio n f ur nish ed in th is sta tem en t is true and correct to the best of our knowledge

and belief.

(President or Other Authorized Officer) Signature

P rin t N a me

Title

Date

(Chief Fiscal Officer) Signature

P rin t N a me

Title

Date

ENCLOSE APPROPR IATE DOCUM ENTS: (Registration Statements W ill Be R eturned U nless Accom panied by A LL R equired D ocum ents)

Ce rtificate of Inco rpor ation, by-law s or oth er or ganiza tional doc um ent an d am end me nts

Certificate of Authority (if incorporated outside New York)