Page 1 of 3 Form CHAR410 (201) Form CHAR410 Registration Statement for Charitable OrganizationsNew York State Department of Law (Office of the Attorney General)Charities Bureau - Registration SectionNew York, NY 10www.charitiesnys.com/ Open to PublicInspectionFor new registrants only(Amending use CHAR410-A,Re-registering use CHAR410-R)Part A - Identification of Registrant1.Full name of organization (exactly as it appears in your organizing document)5.Fed. employer ID no. (EIN) - 2.c/o Name (if applicable)6.Organization222s website3.Mailing address (Number and street)Room/suite7.Primary contactCity or town, state or country and ZIP+4Title4.Principal NYS address (Number and street)Room/suitePhoneFaxCity or town, state or country and ZIP+4EmailPart B - Certification - Two Signatures RequiredWe certify under penalties for perjury that we reviewed this Registration Statement, including all schedules and attachments, and to the best of ourknowledge and belief, they are true, correct and complete in accordance with the laws of the State of New York applicable to this statement. SignaturePrinted NameTitleDate SignaturePrinted NameTitleDatePart C - Fee SubmittedIf registering to solicit contributions, fee is $25.If not registering to solicit contributions, no fee is owed.Check if you are submitting $25 fee toregister to solicit contributions.Submit check or money order,payable to 223NYS Department of Law.224Part D - Attachments - All Documents RequiredAttach all of the following documents to this Registration Statement, even if you are claiming an exemption from registration:225Certificate of incorporation, trust agreement or other organizing document, and any amendments; and225Bylaws or other organizational rules, and any amendments; and225IRS Form 1023 or 1024 Application for Recognition of Exemption (if applicable); and225IRS tax exemption determination letter (if applicable)Part E - Request for Registration ExemptionIs the organization requesting exemption from registration under either or both Article 7-A or the EPTL?.........................G Yes* G No*If 223Yes224, complete Schedule E. 1.President or Authorized Officer/Trustee 2.Chief Financial Officer or Treasurer American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 Form CHAR410 (201) Part F - Organization Structure1.Incorporation / formationa.Type of organization:Corporation........................................GLimited liability company (LLC).........................GPartnership........................................GSole proprietorship..................................GTrust.............................................GUnincorporated association............................GOther *............................................G*If Other, describe:b.Type of corporation if New York not-for-profit corporationA GB GC GD Gc.Date incorporated if a corporation or formed if other than a corporation / / d.State in which incorporated or formed2.List all chapters, branches and affiliates of your organization (attach additional sheets if necessary)NameRelationshipMailing address (number and street, room/suite,City or town, state or country and zip+4)3.List all officers, directors, trustees and key employeesNameTitleMailing address (number and street, room/suite,city or town, state or country and zip+4)End of term(if applicable) / / / / / / / / / / / / / / / / 4.Other Names and Registration Numbersa.List all other names used by your organization, including any prior namesb.List all prior New York State charities registration numbers for the organization, including those from the New York State Attorney General222sCharities Bureau or the New York State Department of State222s Office of Charities Registration American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 Form CHAR410 (201) Part G - Organization Activities1.Month the annual accounting period ends (01-12)2.NTEE code3.Date organization began doing each of following in New York State:a.conducting activity............................................................................ / / b.maintaining assets............................................................................ / / c.soliciting contributions (including from residents, foundations, corporations, government agencies, etc.)......... / / 4.Describe the purposes of your organization5.Has your organization or any of your officers, directors, trustees or key employees been:a.enjoined or otherwise prohibited by a government agency or court from soliciting contributions?.........................G Yes* G No*If 223Yes224, describe:b.found to have engaged in unlawful practices in connection with the solicitation or administration of charitable assets?........G Yes* G No*If 223Yes224, describe:6.Has your organization222s registration or license been suspended by any government agency?..............................G Yes* G No*If 223Yes224, describe:7.Does your organization solicit or intend to solicit contributions (including from residents, foundations, corporations, governmentagencies, etc.) in New York State?............................................................................G Yes* G No*If 223Yes224, describe the purposes for which contributions are or will be solicited:8.List all fund raising professionals (FRP) that your organization has engaged for fund raising activity in NY State (attach additional sheets ifnecessary)NameType of FRP(see instructions for definitions)Mailing address (number and street, room/suite,city or town, state or country and zip+4)Dates of contractPFR................GFRC................GCCV................GStart date: / / End date: / / PFR................GFRC................GCCV................GStart date: / / End date: / / PFR................GFRC................GCCV................GStart date: / / End date: / / Part H - Federal Tax Exempt Status1.If applicable, list the date your organization:a.applied for tax exempt status.................................................................... / / b.was granted tax exempt status.................................................................. / / c.was denied tax exempt status................................................................... / / d.had its tax exempt status revoked................................................................ / / 2.Provide Internal Revenue Code provision:501(c)( ) American LegalNet, Inc. www.FormsWorkFlow.com