Form CHAR410 For new registrants only (Amending use CHAR410-A, Re-registering use CHAR410-R) Registration Statement for Charitable Organizations New York State Department of Law (Office of the Attorney General) Charities Bureau - Registration Section 120 Broadway New York, NY 10271 www.charitiesnys.com/ Open to Public Inspection Part A - Identification of Registrant 1. 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. Organization’s website Room/suite 3. Mailing address (Number and street) City or town, state or country and ZIP+4 7. Primary contact Title Room/suite 4. Principal NYS address (Number and street) City or town, state or country and ZIP+4 Phone Fax Email Part B - Certification - Two Signatures Required We certify under penalties for perjury that we reviewed this Registration Statement, including all schedules and 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 statement. 1. President or Authorized Officer/Trustee Signature Printed Name Title Date Signature Printed Name Title Date 2. Chief Financial Officer or Treasurer Part C - Fee Submitted If registering to solicit contributions, fee is $25. If not registering to solicit contributions, no fee is owed. Check -9 if you are submitting $25 fee to register to solicit contributions. Submit check or money order, payable to “NYS Department of Law.” Part D - Attachments - All Documents Required Attach all of the following documents to this Registration Statement, even if you are claiming an exemption from registration: • Certificate of incorporation, trust agreement or other organizing document, and any amendments; and • Bylaws or other organizational rules, and any amendments; and • IRS Form 1023 or 1024 Application for Recognition of Exemption (if applicable); and • IRS tax exemption determination letter (if applicable) Part E - Request for Registration Exemption Is the organization requesting exemption from registration under either or both Article 7-A or the EPTL? . . . . . . . . . . . . . . . . . . . . . . . . . G Yes* G No * If “Yes”, complete Schedule E. Page 1 of 3 Form CHAR410 (2010) American LegalNet, Inc. www.FormsWorkFlow.com Part F - Organization Structure 1. Incorporation / formation a. Type of organization: Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Limited liability company (LLC) . . . . . . . . . . . . . . . . . . . . . . . . . Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sole proprietorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unincorporated association . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * If Other, describe: b. Type of corporation if New York not-for-profit corporation G G G G G G G AG BG CG DG c. Date incorporated if a corporation or formed if other than a corporation __ __ / __ __ / __ __ __ __ d. State in which incorporated or formed 2. List all chapters, branches and affiliates of your organization (attach additional sheets if necessary) Name Relationship Mailing address (number and street, room/suite, City or town, state or country and zip+4) 3. List all officers, directors, trustees and key employees Name Title Mailing 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 Numbers a. List all other names used by your organization, including any prior names b. List all prior New York State charities registration numbers for the organization, including those from the New York State Attorney General’s Charities Bureau or the New York State Department of State’s Office of Charities Registration Page 2 of 3 Form CHAR410 (2010) American LegalNet, Inc. www.FormsWorkFlow.com Part G - Organization Activities 1. Month the annual accounting period ends (01-12) 2. NTEE code 3. 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 organization 5. 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? . . . . . . . . . . . . . . . . . . . . . . . . . * If “Yes”, describe: G Yes* G No b. found to have engaged in unlawful practices in connection with the solicitation or administration of charitable assets? . . . . . . . . * If “Yes”, describe: G Yes* G No 6. Has your organization’s registration or license been suspended by any government agency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * If “Yes”, describe: G Yes* G No 7. Does your organization solicit or intend to solicit contributions (including from residents, foundations, corporations, government agencies, etc.) in New York State? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * If “Yes”, describe the purposes for which contributions are or will be solicited: G Yes* G No 8. List all fund raising professionals (FRP) that your organization has engaged for fund raising activity in NY State (attach additional sheets if necessary) Type of FRP Name (see instructions for definitions) Mailing address (number and street, room/suite, city or town, state or country and zip+4) Dates of contract PFR . . . . . . . . . . . . . . . . G FRC . . . . . . . . . . . . . . . . G CCV . . . . . . . . . . . . . . . . G Start date: _ _/_ _/_ _ _ _ End date: _ _/_ _/_ _ _ _ PFR . . . . . . . . . . . . . . . . G FRC . . . . . . . . . . . . . . . . G CCV . . . . . . . . . . . . . . . . G Start date: _ _/_ _/_ _ _ _ End date: _ _/_ _/_ _ _ _ PFR . . . . . . . . . . . . . . . . G FRC . . . . . . . . . . . . . . . . G CCV . . . . . . . . . . . . . . . . G Start date: _ _/_ _/_ _ _ _ End date: _ _/_ _/_ _ _ _ Part H - Federal Tax Exempt Status 1. 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)( ___ ) Page 3 of 3 Form CHAR410 (2010) American LegalNet, Inc. www.FormsWorkFlow.com