Professional Licensing Boards and Securities Division 237 Coliseum Drive Macon, GA 31217-3858 (478) 207-2440 http://www.sos.state.ga.us/securities/ Brian P. Kemp Secretary of State Georgia Charitable Solicitations Act Charitable Organization Registration Tanya Battle Executive Director EXECUTION PAGE Statutory Fees (Nonrefundable) Make Check Payable to Georgia Secretary of State INITIAL APPLICATION $35.00 AMENDMENT (No Fee Required) REINSTATEMENT Registration #: _____________ $35.00 WARNING: Failure to keep this form current and file accurate supplemental information on a timely basis, or failure to keep accurate books and records or otherwise comply with provisions of the Georgia Charitable Solicitations Act of 1988, is a violation of said Act and may result in disciplinary, administrative, injunctive or criminal action. INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT MAY CONSTITUTE CRIMINAL VIOLATIONS. 1. Official Name and Mailing Address of Applicant (Charitable Organization): 2. Other Names under which solicitations will be made: 3. Contact Person: Contact Person Email Address for Official Correspondence: 4. Location of Books and Records: Telephone: EXECUTION: On behalf of the applicant identified above, for the purpose of complying with the Charitable Solicitations Act of 1988, as amended (O. C. G. A. 43-17-1 et seq.) ("Act"), I hereby certify that the applicant is in compliance with said Act and irrevocably appoints the Secretary of State of the State of Georgia the agent for the applicant upon whom may be served any notice, process or pleading in any action or proceeding against the applicant arising out of, or founded upon, a violation or an alleged violation of said Act. The applicant hereby consents that any such action or proceeding against said applicant may be commenced in any court of competent jurisdiction and proper venue within the State of Georgia by service of process upon Secretary of State with the same effect as if the applicant was a resident of the State of Georgia and had been personally served with process. The undersigned hereby verifies that he had executed this form on behalf of, and with the authority of, said applicant. The undersigned and applicant represent that the information and statements contained herein, including the exhibits attached hereto, and other information filed herewith, all of which are made a part hereof, are current, true and complete. The undersigned and applicant further represent that to the extent any information previously submitted is not amended, such information is currently accurate and complete. Name of authorized Executive Officer (please type or print): Date: Signature of Executive Officer: Official Witness (Notary) Title: THIS PAGE MUST ALWAYS BE COMPLETED IN FULL with original manual signature and notarization with seal. To amend, circle number(s) being amended. To explain answers attach additional sheets identifying the questions and provide explanation. Form C100 Rev. Sept 2010 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT'S NAME: To amend, circle numbers being amended and file with a completed execution page (C100 page 1) 5. Status of registration in other jurisdictions Enter "1" for pending registrations, "2" if already registered, and leave blank if not registered. AL FL LA NC OK UT AK GA M A ND OR VA AR HI MD NE PA VT AZ IA ME NH PR WA CA ID MI NJ RI WI CO IL MN NM SC W V CT IN MO NV SD WY DC KS MS NY TN D E K Y M T O H TX ORGANIZATION 6. Fiscal Year Ends on (Month/Day): 7. Date of Formation: Place of Filing: Applicant is a: Partnership Corporation Limited Liability Company Proprietorship Other: 8. If FOREIGN Corporation, date qualified to transact business in Georgia: 9. The following financial information must accompany the application in order for registration to become effective: An IRS Form 990 or 990 E-Z dated within one year of filing AND one of the following types of financial statements dated within one year of filing: a. Organizations that received or collected more than $1,000,000 in the preceding fiscal year must submit a financial statement certified by an independent certified public accountant. b. Organizations that received or collected more than $500,000 but less than $1,000,000 must submit a financial statement reviewed by an independent certified public accountant c. Organizations that received or collected less than $500,000 must submit a financial statement. The financial statement does not have to be reviewed or certified. d. If no funds have been received or collected, attach a signed statement to that effect. 10. State the general purpose for which the charitable organization is organized (attach additional sheets if necessary): SOLICITATION INFORMATION 11. Specify the purpose or object for which funds solicited will be used (attach additional sheets if necessary): 12. Specify the method and period of time of solicitation: Form C100 Rev. Sept 2010 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com 13. Does the charitable organization have a contract with a fund raising counsel or paid solicitor to solicit contributions in Georgia? Yes No If the answer to the above question is yes: (a) list the name and address of the fund raising counsel or paid solicitor to be used in connection with the solicitations in Georgia: (b) Terms of remuneration for paid solicitor: (c) Is the paid solicitor registered with the Secretary of State to solicit contributions in Georgia? BACKGROUND INFORMATION To amend, circle questions being amended and file with a completed Execution page (C100 page 1) NOTE: (1) For the purpose of the following questions the term "executive officer" means the chief executive officer, the president, the principal financial officer, the principal operation officer, each vice president with responsibility involving policy-making, the treasurer or any other person performing similar functions. (2) All YES answers to questions must be fully explained. Attach additional sheets as needed. YES NO 14. In the past ten years has the applicant, executive officer, or control person been convicted of or pled guilty or nolo contendere ( no contest) to a felony or misdemeanor which: (a) Involves the solicitation or acceptance of charitable contributions or the making of a false oath, the making ____ ____ of a false report, bribery, perjury, burglary, or conspiracy to commit any of the foregoing offenses? (b) Arises out of the conduct of solicitation of contributions for a