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. Thisstatementcontainsthefactsandfinancialinformationforthefiscalyearending:_____/_____/________ month day year 2. FederalIDNumber(EIN)__________________2a.N.J.CharitiesRegistrationNumber:CH-_________________________ 3. Full legal name of the registering organization:______________________________________________________________ Incareof:(ifnecessary,otherwiseleavethislineblank)__________________________________________________________ Mailing Address:____________________________________________________________________� Change of Address Street Address City State ZIP Code (Leave blank ONLY if this is an initial registration.) 4. 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. Theprincipalstreetaddressoftheregisteringorganization________________________________________________________ Street Address City State ZIP Code � Same as Mailing Address DoestheorganizationhaveanyofficesinNewJerseyinadditiontotheonelistedabove? If"Yes,"attachalistgivingthestreetaddressandtelephonenumberofeachofficeinNewJersey. � Yes � No 6a. Ifthestreetaddresslistedaboveisnotwheretheorganization'sofficialrecordsarekept,oriftheorganizationdoesnotmaintainan officeinNewJersey,indicatethename,fulladdress,phoneandfaxnumberofthepersonhavingcustodyoftheorganization'srecords, and to whom correspondence should be addressed. _______________________________________________________________________________________________________ Contact person Street address City State ZIP Code ________________________________________________________________ Telephone number (include area code) Fax number (include area code) 7. Organization'scontactinformation: ________________________________________________________________ Telephone number (include area code) E-mail address Fax number (include area code) Web site ________________________________________________________________ Form CRI-200 Page 1 of 5 8. TheorganizationiseligibletofileaShortFormRegistrationbecause: a) It did not receive gross contributions in excess of $25,000 in the preceding fiscal year, AND all of the organization's functions,includingfund-raising,areconductedbyvolunteers,members,officersorpersonswhoarenotcompensatedfor 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 confinedtotheorganization'smembershipandperformedbymembersoftheorganization. Yes � No � c) Itsolicitsonbehalfofaspecifiedindividual,andallcontributions,withoutanydeductionswhatsoever,willbeturnedoverto thisbeneficiary. � Yes � No d) Itisalocalpost,camp,chapterorsimilarlydesignatedelementorcountyunit,ofabonafideveterans'organizationwhich 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. Havetherebeenchangesintheorganization'sname,address,InternalRevenueService(I.R.S.)status,etc.sincethedateofyour lastreporting? � 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:amendmenttoincorporation)and/oracopyoftheletterofdeterminationfromtheI.R.S.regardingthetax-exempt-status changes. 9a. Istheorganizationachapterorlocalunitofaparentorganization? � 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. Purposeforwhichtheorganizationwascreated(writeinorattachastatementtothisregistration):_______________________ ______________________________________________________________________________________________________ 10a. Does the organization solicit or intend to solicit contributions from the general public in the State of New Jersey (including through thesaleofmerchandise)?� Yes � No If "Yes," explain the purpose for which solicited funds are being raised (write in or attach a statement to this registration): _______________________________________________________________________________________________________ 10b.Doestheorganizationsolicitfundsunderanyothername(s)?� Yes � No If"Yes,"pleaseattachtothisregistrationalistofallothernamesused:_________________________________________ 11. Doestheorganizationregisterorsolicitinotherstates?� Yes � No If"Yes,"pleaseindicateotherstateshereor,ifnecessary,attachtothisregistrationalistofthosestates.__________________ 11a.Hastheorganizationeverbeenenjoi