New Jersey Office of the Attorney General Division of Consumer Affairs Office of Consumer Protection Charities Registration Section 124 Halsey Street, 7th Floor, P.O. Box 45021 Newark, NJ 07101 (973) 504-6215 Form CRI-200 Short-Form Registration/Verification Statement (Revised April 2008) All questions must be answered. Charitable organizations, domiciled or doing business in the State of New Jersey, which receive gross contributions of $25,000 or less per year, are required to submit an initial registration and to renew registration annually. In both circumstances this form may be used. In the event an organization receives gross contributions of less than $10,000 per year and does not compensate anyone to solicit or perform fund-raising activities on its behalf, the organization is exempt from registration, but may still choose to register. The registration fee for charities with gross contributions between $0 and $25,000 is $30, whether the fee is for an initial or renewal registration. Payment is to be made by check or money order, made payable to the “New Jersey Division of Consumer Affairs,” and is due at the time of submission of the form. 1a. This statement is an £ Initial £ Renewal Registration (check one only.) 1b. This statement contains the facts and financial information for the fiscal year ending: _____/ _____/ ________ month day year 2. Federal ID Number (EIN) __________________ 2a. N.J. Charities Registration Number: CH- _________________________ (Leave blank ONLY if this is an initial registration.) 3. Full legal name of the registering organization: ______________________________________________________________ In care of: (if necessary, otherwise leave this line blank) __________________________________________________________ 4. Mailing Address: ____________________________________________________________________ £ Change of Address Street Address City State ZIP Code NOTE: If “ in care of,” a postal, private or rural delivery mail box number is used, the street address of the charity must be given below. 5. 6. The principal street address of the registering organization________________________________________________________ Street Address City State ZIP Code £ Same as Mailing Address Does the organization have any offices in New Jersey in addition to the one listed above? If “Yes,” attach a list giving the street address and telephone number of each office in New Jersey. £ Yes £ No 6a. If the street address listed above is not where the organization’s official records are kept, or if the organization does not maintain an office in New Jersey, indicate the name, full address, phone and fax number of the person having custody of the organization’s records, and to whom correspondence should be addressed. _______________________________________________________________________________________________________ Contact person Street address City ________________________________ ________________________________ Telephone number (include area code) Fax number (include area code) 7. Organization’s contact information: ________________________________ ________________________________ Telephone number (include area code) Fax number (include area code) ________________________________ ________________________________ E-mail address Web site Form CRI-200 Page 1 of 5 State ZIP Code 8. The organization is eligible to file a Short Form Registration because: a) It did not receive gross contributions in excess of $25,000 in the preceding fiscal year, AND all of the organization’s functions, including fund-raising, are conducted by volunteers, members, officers or persons who are not compensated for soliciting contributions. £ Yes £ No b) It is a fraternal, patriotic, social or alumni organization, historical society or similar organization organized under the provisions of Title 15 of the New Jersey Revised Statutes or Title 15A of the New Jersey Statutes, AND solicitation of contributions is confined to the organization’s membership and performed by members of the organization. Yes £ No £ c) It solicits on behalf of a specified individual, and all contributions, without any deductions whatsoever, will be turned over to this beneficiary. £ Yes £ No d) It is a local post, camp, chapter or similarly designated element or county unit, of a bona fide veterans’ organization which issues charters to the local elements throughout New Jersey or to any veterans’ organization chartered under federal law or a service foundation of such an organization recognized in the organization’s by-laws. Yes £ No £ e) It is a private foundation that raised less than $25,000 in public contributions. £ Yes £ No Note to question 8: If after reviewing the answers to questions 8a through 8e, none of the statements can be answered “Yes,” the charity is not eligible to use the Short-Form CRI-200 and instead must use the Long-Form Initial Registration Statement CRI-150-I or the Long-Form Renewal Statement CRI-300R. 9. Have there been changes in the organization’s name, address, Internal Revenue Service (I.R.S.) status, etc. since the date of your last reporting? £ Yes £ No If “Yes,” please provide the details on a separate sheet of paper, and provide copies of the documentary proof of a name change (example: amendment to incorporation) and/or a copy of the letter of determination from the I.R.S. regarding the tax-exempt-status changes. 9a. Is the organization a chapter or local unit of a parent organization? £ Yes £ No If “Yes,” write in the full name, address and phone number (include the area code) of the parent organization. Please do not use abbreviations. _______________________________________________________________________________________________________ 10. Purpose for which the organization was created (write in or attach a statement to this registration): _______________________ ______________________________________________________________________________________________________ 10a. Does the organization solicit or intend to solicit contributions from the general public in the State of New Jersey (including through the sale of merchandise)? £ Yes £ No If “Yes,” explain the purpose for which solicited funds are being raised (write in or attach a statement to this registration): _______________________________________________________________________________________________________ 10b. Does the organization solicit funds under any other name(s)? £ Yes £ No If “Yes,” please attach to this registration a list of all other names used: _________________________________________ 11. Does the organization register or solicit in other states? £ Yes £ No If “Yes,” please indicate other states here or, if necessary, attach to this registration a list of those states. __________________ 11a. Has the organization ever been enjoined in any jurisdiction from soliciting contributions or has it been found to have engaged in unlawful practices in the solicitation of contributions or the administration of charitable assets? £ Yes £ No If “Yes,” list the jurisdiction and attach copies all of the relevant documents. _________________________________________ 11b. Has the organization’s charity registration been denied, suspended or revoked by any jurisdiction or state? £ Yes £ No 11c. Has the organization voluntarily entered into an assurance of voluntary compliance agreement or any similar order or legal agreement with any jurisdiction, state or federal agency or officer? £ Yes £ No Form CRI-200 Page 2 of 5  12. If the answer to 11a, 11b or 11c is “Yes,” please attach to this registration a statement that provides the details of the action, together with the reason(s) for that denial, suspension, revocation, injunction, compliance agreement etc., including the state or jurisdiction involved, the dates and full copies of all related documents. Indicate the attachment of documents to this Registration/Verification Statement by checking this box: £ 13. Is the organization currently I.R.S. tax-exempt? £ Yes £ No If “Yes,” under which section of the code?___________________________________________ 14. Has the organization’s tax-exempt status been revoked, changed, or refused by the I.R.S.? £ Yes £ No If “Yes,” please attach to this registration a statement providing an explanation, including all of the facts, dates, and all letters and notices received from the I.R.S. 15. Has the organization used an independent paid fund-raiser, fund-raising counsel or commercial co-venturer? £ Yes £ No If “Yes,” for what purpose(s) are funds being raised? ____________________________________________________________ 15a. If the answer to question 15 is “Yes,” write in or provide a separate listing of the name(s) of all independent paid fund-raiser(s), fund-raising counsel and/or commercial co-venturer(s):__________________________________________________________ 16. Provide on a separate sheet of paper the name, title, street address, telephone number and salary of each officer, director and trustee, and the five most-highly compensated employees in the organization. Indicate the attachment of documents to this Registration/Verification Statement by checking this box: £ 16a. Has any person listed in the response to question 16 been adjudged liable in any administrative or civil action, or been convicted in a criminal action involving theft, fraud or deceptive business practices? £ Yes £ No If the response is “Yes,” please provide all of the details on a separate sheet and also attach to this registration a copy of the order, judgment or other document(s) indicating final disposition of the matter. Please note: For the purpose of question 16a, a plea of guilty, non vult, nolo contendere or any similar disposition of the alleged activity shall be deemed a conviction. A judgment of liability in an administrative or civil action would include a finding or admission that the individual engaged in an unlawful practice relating to the solicitation of contributions or the administration of charitable assets. We understand that this registration is being issued at the discretion of the Division of Consumer Affairs and agree that employees of the Division may inspect the records in the possession of this organization in order to ascertain compliance with the statute and all pertinent regulations. We also understand that we may be required to provide additional information if requested. We hereby certify that the above information and the attached financial schedule(s) and statement(s) are true. We are aware that if any of the above statements are willfully false, we are subject to punishment. Signature____________________________ Name______________________________ Title ______________ Date ____________ Signature____________________________ Name______________________________ Title ______________ Date ____________ This form must be signed by two (2) authorized officers of the organization, including the chief financial officer. Form CRI-200 Page 3 of 5 CRI-200 Short-Form Registration Verification Financial Statement Note: If the financial value of a line item = 0, place a zero in the space provided. Please report all figures as GROSS, not NET. Full legal name and street address of the organization Full legal name:__________________________________________________________________________________________ Fiscal year-end being reported: _____/_____/_____ Federal ID Number (EIN) __________________ month day year Mailing address: _______________________________________________________________________________________________________ Street address of the registering organization: __________________________________________________________________ Street Address C ity State ZIP Code New Jersey Charities Registration number: CH _______________ -00 Telephone number: _________________________ (include area code) Mailing Address P.O. Box Number or Suite C ity State ZIP code A. Revenue Line A1. Contributions & Donations: Includes but is not limited to individual and corporate contributions, donations, legacies, bequests and gross receipts from fundraising: A1a. Direct Public Support …………………………………........................ _ _________________ A1b. Indirect Public Support (including donations from other charities) ..... __________________ A1c. Gross Contributions (add lines 1a and 1b) .......................................... __________________ Line A2. Government Grants .......................................….............................................. _ _________________ Line A3. Other Income A3a. Membership dues and assessments ……………………........................ _ _________________ A3b. Interest and dividends ............................................................................ _ _________________ A3c. Program service revenue ………………………………........................ _ _________________ A3d. Gain from sale of assets ......................................................................... _ _________________ A3e. Other income (please specify on a separate statement): ........................ __________________ A3f. Donations from founder(s) of private foundation ................................. __________________ A3g. Total other income.................................................................................. _ _________________ Line A4. Total Gross Revenue (add lines A1c, A2 and A3g)…..................................... __________________ B. Expenses Line B1. Program …………………………………................... .................................... Line B5. Total Expenses (add lines B1, B2, B3 and B4)………................................... __________________ C. Excess or Deficit Line C1. Excess or deficit for the year-end noted above (subtract line B5 from A4):.... __________________ _ _________________ Line B2. Management, office and general expenses………………............................... __________________ Line B3. Fund-raising expenses…………………………….................... ..................... . _ _________________ Line B4. Payments to state/national affiliates (if applicable)…………………............. __________________ Please Note: The amount of Gross Contributions ( line A1c on this form) determines the registration fee which must be paid and the form which should be used. July 2006 revisions to the Charities Registration Act now require all charities to pay a registration fee, including charities whose Gross Contributions are less than $10,000. Further information for charity registrants may be found on our Web site: http://www.njconsumeraffairs.gov/ocp/charities.htm Form CRI-200 Page 4 of 5 Registrants who are qualified to file the Short-Form Registration/Verification Statement CRI-200 must submit the following: (1) A completed signed Short-Form Registration Statement CRI-200 with all questions answered, including all lists, statements and attachments as may be required by the answers given to the form’s questions. (2) A check or money order in the amount of $30, even if gross contributions did not exceed $10,000. Annual renewal registrations are due within six months of the fiscal year-end. If filing after the due date, please include the $25 late fee due. Checks should be made payable to the “New Jersey Division of Consumer Affairs.” (3) Except when submitting an initial registration, the organization’s charities registration number should be written on all checks, forms, attachments, documents etc. being submitted. (4) If the charity was required by the Internal Revenue Service to file an IRS-990 for the fiscal year-end being reported, a copy of the I.R.S. 990 (or 990EZ or 990PF etc.) must be submitted along with the Schedule A and all of the statements, attachments, schedules etc. which were originally attached to the copy submitted to the I.R.S. (5) Photocopies of any orders, judgments, agreements or other documents which show the final disposition of any civil or criminal actions brought against the organization or its board members, marked with the related question number and the charities registration number. (6) Only initial registrants are required to submit photocopies of the organization’s bylaws, certificate of incorporation and I.R.S. determination letter. However, copies of these documents must be resubmitted each time they are amended. (7) Mail the completed registration, enclosures and any attachments to the: New Jersey Division of Consumer Affairs Charities Registration & Investigation Section P.O. Box 45021 Newark, NJ 07101 Should you have questions regarding charities registration in New Jersey, please visit our Web site at http://www.njconsumeraffairs.gov/ocp/charities.htm where registration information, instructions, forms and a fee schedule may be viewed and/or downloaded. After reading through all of the information on our Web site, if you have further questions, please contact the Charities Registration Section at our hotline number (973)-504-6215 during regular business hours. Form CRI-200 Page 5 of 5