Form Annual Filing for Charitable Organizations CHAR500 2009 New York State Department of Law (Office of the Attorney General) Charities Bureau - Registration Section 120 Broadway New York, NY 10271 http://www.charitiesnys.com This form used for Article 7-A, EPTL and dual filers (replaces forms CHAR 497, CHAR 010 and CH AR 006) Open to Public Inspection 1. General Information / 2 0 0 9 and ending (mm/dd/yyyy) a. For the fiscal year beginning (mm/dd/yyyy) b. Check if applicable for NYS: G G G G G G c. N am e of organization d. Fed. em ployer ID no. (E IN ) (##-#######) Address change e. N Y S tate registration no. (##-##-##) Name change Initial filing N um ber and street (or P.O . box if m ail not delivered to street address) Final filing R oom /suite f. T elephone num ber Amended filing NY registration pending C ity or town, state or country and zip + 4 g. E m ail 2. Certification - Two Signatures Required We certify under penalties of perjury that we reviewed this report, including all attachments, and to the best of our knowledge and belief, they are true, correct and complete in accordance with the laws of the State of New York applicable to this report. a. President or Authorized Officer S ignature P rinted N am e T itle D ate S ignature P rinted N am e T itle D ate b. Chief Financial Officer or Treas. 3. Annual Report Exemption Information a. Article 7-A annual report exemption (Article 7-A registrants and dual registrants) Check - if total contributions from NY State (including residents, foundations, corporations, government agencies, etc.) did not exceed $25,000 and the organization did not engage a professional fund raiser (PFR) or fund raising counsel (FRC).to solicit contributions during this fiscal year. NOTE: An organization may claim this exemption if no PFR or FRC was used and either: 1) it received an allocation from a federated fund, United Way or incorporated community appeal and contributions from other sources did not exceed $25,000 or 2) it received all or substantially all of its contributions from one government agency to which it submitted an annual report similar to that required by Article 7-A. b. EPTL annual report exemption (EPTL registrants and dual registrants) Check - if gross receipts did not exceed $25,000 and assets (market value) did not exceed $25,000 at any time during this fiscal year. For E P T L or A rticle-7A registrants claim ing the annual report exem ption under the one law under which they are registered and for dual registrants claim ing the annual report exem ptions under both laws, sim ply com plete part 1 (G eneral Inform ation), part 2 (C ertification) and part 3 (A nnual R eport Exem ption Inform ation) above. D o not subm it a fee, do not complete the following schedules and do not subm it any attachm ents to this form . 4. Article 7-A Schedules If you did not check the Article 7-A annual report exemption above, complete the following for this fiscal year: a. Did the organization use a professional fund raiser, fund raising counsel or commercial co-venturer for fund raising activity in NY State? . . G Yes* G No * If “Yes”, complete Schedule 4a. b. Did the organization receive government contributions (grants)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G Yes* G No * If “Yes”, complete Schedule 4b. 5. Fee Submitted: See last page for summary of fee requirements. Indicate the filing fee(s) you are submitting along with this form: a. Article 7-A filing fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________ Submit only one check or money order for the b. EPTL filing fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________ total fee, payable to “NYS Department of Law” c. Total fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________ 6. Attachments - For organizations that are not claiming annual report exemptions under both laws, see last page for required attachments ººº 1 CHAR500 - 2009 American LegalNet, Inc. www.FormsWorkFlow.com Schedule 4a: Professional Fund Raisers (PFR), Fund Raising Counsels (FRC), Com mercial Co-Venturers (CCV) If you checked the box in question 4.a. on page 1, complete the following schedule for each PFR, FRC or CCV that the organization engaged for fund raising activity in NY State: 1. Type of fund raising professional (FRP): Professional fund raiser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fund raising counsel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Commercial co-venturer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. G G G Name of FRP: Number and street (or P.O. box if mail is not delivered to street address): City or town, state or country and zip + 4: 3. FRP telephone number: 4. Services provided by FRP (provide description): 5. Compensation arrangement with FRP (provide description): 6. Dates of contract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _____________________ through _____________________ (mm/dd/yyyy) (mm/dd/yyyy) 7. Amount paid to FRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _____________________ 8. If services were provided by a CCV, did the CCV provide the charitable organization with the interim report(s) required by §§ 173-a. 3 of the Executive Law? ) 2 CHAR500 - 2009 American LegalNet, Inc. www.FormsWorkFlow.com Schedule 4b: Governm ent Contributions (Grants) If you checked the box in question 4.b. on page 1, complete the following schedule for each government contribution (grant). Use additional copies of this page if necessary to list each government contribution (grant) separately. Government Agency Name Grant Amount $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Governm ent Contributions (Grants) 3 CHAR500 - 2009 $ American LegalNet, Inc. www.FormsWorkFlow.com 5. Fee Instructions The filing fee depends on the organization’s Registration Type. For details on Registration Type and filing fees, see the Instructions for Form CHAR500. Organization’s Registration Type Fee Instructions • Article 7-A Calculate the Article 7-A filing fee using the table in part a below. The EPTL filing fee is $0. • EPTL Calculate the EPTL filing fee using the table in part b below. The Article 7-A filing fee is $0. • Dual Calculate both the Article 7-A and EPTL filing fees using the tables in parts a and b below. Add the Article 7-A and EPTL filing fees together to calculate the total fee. Submit a single check or money order for the total fee. a) Article 7-A filing fee Total Support & Revenue Article 7-A Fee more than $250,000 up to $250,000 * b) * Any organization that contracted with or used the services of a professional fund raiser (PFR) or fund raising counsel (FRC) during the reporting period must pay an Article 7-A filing fee of $25, regardless of total support and revenue. $25 $10 EPTL filing fee Net Worth at End of Year EPTL Fee Less than $50,000 $25 $50,000 or more, but less than $250,000 $50 $250,000 or more, but less than $1,000,000 $100 $1,000,000 or more, but less than $10,000,000 $250 $10,000,000 or more, but less than $50,000,000 $750 $50,000,000 or more $1500 6. Attachments – Document Attachment Check-List Check the boxes for the documents you are attaching. For All Filers Filing Fee G Single check or money order payable to “NYS Department of Law” Copies of Internal Revenue Service Forms G IRS Form 990 G All required schedules (including Schedule B) G IRS Form 990-T G IRS Form 990-EZ G All required schedules (including Schedule B) G IRS Form 990-T G IRS Form 990-PF G All required schedules (including Schedule B) G IRS Form 990-T Additional Article 7-A Document Attachment Requirement Independent Accountant’s Report G G G Audit Report (total support & revenue more than $250,000) Review Report (total support & revenue $100,001 to $250,000) No Accountant’s Report Required (total support & revenue not more than $100,000) ) 4 CHAR500 - 2009 American LegalNet, Inc. www.FormsWorkFlow.com