New Jersey Office of the Attorney General Division of Consumer Affairs Office of Consumer Protection Charities Registration Section 153 Halsey Street, 7th Floor, P.O. Box 45021 Newark, NJ 07101 (973) 504-6215 Form CRI-150-I Long-Form Initial Registration/Verification Statement (Revised April 2008) All of the questions must be answered. 1. 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. The principal street address of the registering organization________________________________________________________ Street Address City State ZIP Code £ Same as Mailing Address 6. 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 of the organization’s records, and to whom correspondence should be addressed. _______________________________________________________________________________________________________ Contact person ________________________________ Telephone number (include area code) Street address City ________________________________ State ZIP 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 8. Type of organization (check one): £ Nonprofit corporation £ Partnership £ Foundation Individual £ Association £ £ Society £ Trust Other (Specify) ____________________________________ £ 9. Where and when was the organization legally established? Date: ____________________State: ________________ As required by the C.R.I. Act (N.J.S.A. 45:17A-24c(1)), attach to this registration a copy of the organization’s bylaws and instrument of organization (that is, the organization’s charter, articles of incorporation or organization, agreement of association, instrument of trust, or constitution). -1- American LegalNet, Inc. www.FormsWorkflow.com 10. Does the organization solicit funds under any name or names other than as indicated on line 2 of this form? £ Yes £ No If “Yes,” indicate all of the other names used: _________________________________________________________________ 11. Does the organization intend to solicit contributions from the general public? Yes £ £ No 12. Is the organization authorized by any other state or jurisdiction to solicit contributions? Yes £ No £ If “Yes,” please provide a list of those states or jurisdictions, below or on a separate sheet of paper. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 13. Does the organization have affiliates which share the contributions or other revenue it raised in New Jersey? Yes £ No £ If “Yes,” provide a separate listing of those affiliates indicating the name, street address and telephone number for each one. 14. What is the charitable purpose or purposes for which the organization was formed? If necessary, attach a separate statement to this registration. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 14a. What are the specific programs and charitable purposes for which contributions are used? For each program, state whether it already exists or is planned. Only major program categories need be listed. If necessary, attach a separate statement to this registration. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 15. Does the organization use an independent paid fund-raiser or fund-raising counsel? £ Yes £ No If “Yes,” please attach to this registration a list of paid fund-raiser(s) or fund-raising counsel(s), including their full address, telephone number, fax number, registration number in New Jersey, and a contact person’s name. 15a. Does the independent paid fund-raiser or fund-raising counsel have custody, control or access to the organization’s funds? £ Yes £ No If “Yes,” please describe the situation. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 16. Has the organization permitted a charitable sales promotion to be conducted on its behalf by a commercial co-venturer during the fiscal year-end being reported ? £ Yes £ No If “Yes,” please explain: ___________________________________________________________________________________ _______________________________________________________________________________________________________ 17. Has the Internal Revenue Service (I.R.S.) determined that the organization is tax exempt under code 502(c)? Yes £ a. If “Yes,” attach a photocopy of the Federal Tax Exemption determination letter issued by the I.R.S. b. If “No,” has an application been filed which is still pending? Yes £ c. Also, if “No,” has an I.R.S. tax exemption been refused, changed or revoked? Yes £ If an exemption has been refused, changed or revoked, attach to this registration a copy of the I.R.S. determination notification and provide a detailed explanation of the circumstances on a separate sheet of paper. £ No £ No £ No letter of 18. Has the organization ever had its authority to conduct charitable activities denied, suspended, or revoked in any jurisdiction or has the organization ever entered into any voluntary agreement of discontinuance with any governmental entity? Yes £ No £ If “Yes,” attach to this registration a copy of the denial, suspension, revocation or voluntary agreement of discontinuance. If the document does not explain the reasons for the denial, suspension or revocation, attach to this registration an explanation on a separate sheet of paper. 19. Has the organization voluntarily entered into an assurance of voluntary compliance or similar order or agreement (including, but not limited to, a settlement of an administrative investigation or proceeding, with or without an admission of liability) with any jurisdiction, state or federal agency or officer? Yes £ No £ If “Yes,” please attach to this registration the relevant document. -2- American LegalNet, Inc. www.FormsWorkflow.com 20. Has the organization or any of its present officers, directors, executive personnel or trustees ever been found to have engaged in unlawful practices in the solicitation of contributions or administration of charitable assets or been enjoined from soliciting contributions, or are such proceedings pending in this or any other jurisdiction? Yes £ No £ If “Yes,” attach to this registration photocopies of any and all written documentation (such as a court order, administrative order, judgment, formal notice, written assurance or other document) which show the final disposition of the matter. 21. Has the organization or any of its present officers, directors, trustees or principal salaried executive staff employees ever been convicted of any criminal offense committed in connection with the performance of activities regulated under this act or any criminal or civil offense involving untruthfulness or dishonesty or any criminal offense relating adversely to the registrant’s fitness to perform activities regulated by this act? A plea of guilty, non vult, nolo contendere or any similar disposition of alleged criminal activity shall be deemed a conviction. Yes £ No £ 22. Has the organization or any of its officers, directors, trustees or principal salaried executive staff employees been adjudged liable in any administrative or civil action involving theft, fraud, or deceptive business practices? For purposes of this question a judgment of liability in an administrative or civil action shall include, but is not limited to, any finding or admission that the individual engaged in an unlawful practice in relation to the solicitation of contributions or the administration of charitable assets. Yes £ No £ If “Yes,” identify the individual(s) below and attach to this registration a copy of any order, judgment or other documents indicating the final disposition of the matter. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 23. Provide the following information for each officer, director, trustee and the five most-highly compensated executive staff employees: Name Business address Telephone number Relationship Salary _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ ______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ -3- American LegalNet, Inc. www.FormsWorkflow.com CRI- 150-I Long-Form Registration Initial 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: _______________________________________________________________________________________________________ Mailing Address P.O. Box Number or Suite City State ZIP code Street address of the registering organization: __________________________________________________________________ Street City State ZIP Code Address New Jersey Charities Registration number: CH _______________ -00 Telephone number: _________________________ (include area code) Attach to this registration the most recent Internal Revenue Service Form 990 and Schedule A (990), if the organization has filed those forms. Attach a copy if the organization’s annual financial report included an audited financial statement, or if the organization received gross revenue in excess of $250,000. Note: If the organization received gross revenue of less than $250,000, the financial reports must be certified by the organization’s president or other authorized officer of the organization’s board. £ In lieu of completing the CRI-300R Financial Statement pages, attached please find a copy of the I.R.S. 990 filing for the fiscal year-end indicated above. A. Receipts Line A1a. Direct Public Support received from the following sources: (1) Direct mail ……………………………………….... __________________ (2) Telephone solicitation…………………………….... __________________ (3) Commercial co-venture…………………………..... __________________ (4) Gross receipts from fund-raising events…………… __________________ (5) Canisters, counter cards, door to door etc…………. __________________ (6) Corporations and other businesses…………………. __________________ (7) Foundations and trusts……………………………... __________________ (8) Donated land, buildings, property, equipment and materials……………………………………………. __________________ (9) Legacies and bequests……………………………… __________________ (10) Membership dues solely resulting from solicitations………………………………................ __________________ (11) Other support (specify)…………………………...... __________________ Line A1b. Total Direct Public Support (add lines A1a(1) through A1a(11) ...… __________________ Line A1c. Indirect Public Support received from the following sources: (1) Federated fund-raising organization……………….. __________________ (2) From an affiliated organization…………………….. __________________ (3) From another fund-raising organization………….... __________________ Line A1d. Total Indirect Public Support (add lines Alc(1) thru A1c(3))…........ __________________ Line A1e. Total Gross Contributions (add lines A1b and A1d) ………...…… __________________ Please Note: The amount of Gross Contributions ( line A1e 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 -4- American LegalNet, Inc. www.FormsWorkflow.com  Line A2. Government grants including purchase of service contracts (specify agency) a. …………………………………………………................ __________________ b. …………………………………………………................ __________________ c. …………………………………………………................ __________________ d. …………………………………………………................ __________________ Line A2e. Total Government Grants (add lines 2a thru 2d)…..………………..... __________________ Line A3. Other Support a. b. c. d. Bona fide membership ………………………................... __________________ Program service revenue…………………….................... __________________ Professional services rendered by volunteers………......... __________________ Miscellaneous income (specify)………………................. __________________ Line A3e. Total Other Support (add the total of lines A3a thru A3d)…..…........ __________________ Line A4. Total Gross Revenue (add lines A1e, A2e and A3e) ………..…...... __________________ B. Expenses Line B1. Line B2. Line B3. Line B4. Line B5. Program expenses…………………………………................... __________________ Management and general expenses……………….................... __________________ Fund-raising expenses…………………………….................... __________________ Payments to states and national affiliates (if applicable)…........ __________________ Total Expenses (add the totals of line B1 thru B4)…..……...... __________________ C. Excess or Deficit For the fiscal year-end (subtract line B5 from line A4)…………….................. __________________ D. Fund Balance Line D1. Line D2. Line D3. Fund balance at beginning of the year……………………….... __________________ Excess or deficit (line C above) ………………......................... __________________ Fund balance at the end of the year (subtract D2 from D1)…... __________________ -5- American LegalNet, Inc. www.FormsWorkflow.com Long-Form Initial Registration Statement Form CRI-150-IC Confidential Information Organization’s Name: _________________________________________________________________________________ N.J. Charities Registration Number: CH -__________ -00 Fiscal Year-End being reported: ____ / _____ / ____ month day Federal ID Number (EIN) ___________________ Telephone number: _________________________ year (include area code) 24. Are any of the organization’s officers, directors, trustees or the five most-highly compensated employees related by blood, marriage or adoption to: a. b. c. d. each other? Yes £ No £ any officers, agents or employees of any fund-raising counsel or independent paid fund-raiser under contract to the organization? Yes £ No £ any chief executive, employee, any other employee of the organization with a direct financial interest in the transaction, or any partner, proprietor, director, officer, trustee, or to any shareholder of the organization with more than two (2) percent interest in any supplier or vendor providing goods or services to the organization? Yes £ No £ If you answered “Yes,” to questions 24a, b, or c, please provide a statement explaining these relationships. 25. Do any of the organization’s officers, directors, trustees or the five most-highly compensated employees have a financial interest in any activities engaged in by a fund-raising counsel or independent paid fund-raiser under contract to the organization, or any supplier or vendor providing goods or services to the organization? £ Yes £ No If “Yes,” please detail these relationships below or on a separate sheet of paper, and provide the name, business address and telephone number of all interested parties. 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. Note: Form CRI-150-IC must be filed with Form CRI-150-I. -6- American LegalNet, Inc. www.FormsWorkflow.com Initial registrants who are required to file the Long-Form Initial Registration/Verification Statement CRI-150-I/IC must submit the following: (1) A completed Long-Form Registration Statement CRI-150-I and IC with all of the questions answered and required lists attached. (2) All charity registrants in New Jersey must pay a registration fee based on gross contributions. Please visit our Web site at www.njconsumeraffairs.gov for a complete schedule of registration fees due. A check or money order for the registration fee due, made payable to the New Jersey Division of Consumer Affairs, must accompany the registration form. Cash or credit card payments cannot be accepted. Initial registrations must be submitted prior to soliciting in the State of New Jersey. Registrations must be renewed annually, and are due within six months of the fiscal year-end. Extensions of time to file cannot be granted on initial (first-time) registrations. (3) Charity registrants with total gross revenue in excess of $250,000 annually are required to submit a certified audit (including any management letters) which has been prepared by a certified public accountant. (4) Please write the organization’s charities registration number on all checks, forms, and copies of documents submitted. (5) If the charity was required by the Internal Revenue Service to file an IRS-990 form for the organization’s fiscal year-end being reported, a copy, including Schedule A, must be submitted with the registration form. (6) 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, must be marked with the related question number and the charities registration number. (7) Only initial registrants must submit photocopies of the organization’s bylaws, the certificate of incorporation and the I.R.S. determination letter. However, copies of these documents must be resubmitted each time they are amended. (8) 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. -7- American LegalNet, Inc. www.FormsWorkflow.com