Form Ss-6042 - Annual Request For 30,000 Dollars And Under Exemption - 2016 Page 2
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210. Does the organization intend to solicit and receive more than $30,000 in gross contributions from
the public during any accounting year? Yes
No
11. Has the organization received more than $30,000 in gross contributions from the public during
any accounting year? Yes
No
12. Attach a copy of the IRS Form 990 from the most recently completed accounting year, if required
to submit a 990.
13. Attach a completed copy of the Summary of Financial Activities form
14. Describe the charitable purpose of the organization.
Note: You must register with the Secretary of State within thirty (30) days if gross contributions from the
public exceed thirty thousand dollars ($30,000).
Signature: This document must be signed by an authorized officer. I certify that the statements in this
document and all supplemental forms, documents, and continuation sheets are true and correct to the
best of my knowledge and belief.
Signature of Authorized Officer:
Salutation:
First:
MI:
Last:
Position Title:
Date:
SS-6042 (Revised 12/16), RDA 2994
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