North Carolina Department of the Secretary of State Charitable Solicitation Licensing Initial License Application Form for charitable or sponsor organizations 1. Applicant Organization’s Full Legal Name: 2. Applicant’s Principal Telephone Number (include area code): 3. Applicant’s Principal Street Address, including City, State Code, and Zip Code (do not use a P.O. Box address): 4. Name under which you intend to solicit contributions: 5. Describe the purpose for which you are organized: 6. Describe the purpose for which contributions will be used: 7. Are you incorporated? YES: Provide the following information: A. State of Incorporation: ___________________________ B. Date of Incorporation: ____________________________ C. Fiscal year end (day/month): _______________________ NO: Provide the following information: D. Organization type/description: _______________________________________ E. State where formed (e.g., NC): ______________________ F. Date formed: ______________________ G. Fiscal year end (day/month): ______________________ 8. Have you received a federal tax exemption determination letter? YES: Provide the following information: A. Attach one (1) copy of your federal tax exemption determination letter. B. State your federal tax exemption code designation (e.g., “501(c)(3)”): __________________ NO. 9. Are you authorized by any other state to solicit contributions? YES: Attach a list of these states. | NO. 10. Have you or any of your officers, directors, trustees, or salaried executive personnel been enjoined or prohibited in any jurisdiction from soliciting contributions? YES: Attach an explanatory statement. | NO. 11. Have you or any of your officers, directors, trustees, or salaried executive personnel been found to have engaged in unlawful practices in the solicitation of contributions or the administration of charitable assets? YES: Attach an explanatory statement. | NO. 12. Do you compensate any of your officers, trustees, organizers, incorporators, fundraisers, or solicitors? YES. | NO. 13. Name the individual(s) or officer(s) in charge of any solicitation activities: 14. Other than your principal office identified above, do you maintain any office locations in North Carolina? YES: Attach a list identifying the street address and telephone number for each additional office location in North Carolina. NO. 15. Do you maintain your principal office outside North Carolina and possess no other office location in North Carolina? YES: Attach the name, street address, and telephone number of the person who has custody of your financial records. NO. CSL Contact Information: Agency Internet Site: www.sosnc.com Electronic Mail: csl@sosnc.com Telephone: (919) 807-2214 - Toll free for NC residents: 1-888-830-4989 Facsimile: (919) 807-2220 Mailing Address: P.O. Box 29622, Raleigh, NC 27626-0622 Initial License Application Form for charitable or sponsor organizations Form Revision: 1 Effective Date: August 2, 2005 Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com North Carolina Department of the Secretary of State Charitable Solicitation Licensing Initial License Application Form for charitable or sponsor organizations 16. Have you ever had your authority denied, suspended, or revoked by any governmental agency? YES: Attach a statement of the reasons for each denial, suspension, or revocation. NO. 17. Have you ever entered into any assurance of voluntary compliance or similar agreement? YES: Attach one (1) copy of each agreement. NO. 18. Do you have any contract(s) with any person who qualifies as a fund-raising consultant, solicitor, or coventurer that (1) is currently active or (2) has been completed within the past fiscal year? YES: Attach one (1) completed fundraising disclosure form for each contract relationship. NO. 19. Are you a new organization with no prior financial history? YES: Provide the following information: A. Attach one (1) copy of your organization’s budget for the current fiscal year. B. Attach a list identifying your officers, directors, trustees, and salaried executive personnel, including names and street addresses (not P.O. Box addresses). C. Attach a list of the names, street addresses, and telephone numbers of the individuals or officers who have final responsibility for the custody and distribution of contributions. D. Attach a description of your organization’s major program activities. Skip Items 20, 21, and 22. Proceed to Item 23. NO. Proceed to Item 20. 20. Annual Financial Information Reporting: Choose one (1) financial information reporting option for this application: Check here if choosing Option 1: filing federal tax forms. Proceed to Item 21. Check here if choosing Option 2: filing state forms. Skip Item 21. Proceed to Item 22. 21. Option 1: filing federal tax forms: Provide the following information: A. Attach a signed and completed federal Form 990 or Form 990-EZ, Schedule A, and attachments (except Schedule B) for the preceding fiscal year. B. Do your federal forms and attachments list post office box addresses for any officer, director, trustee, salaried executive personnel, or individual responsible for custody and distribution of contributions? YES. Identify a street address the Department or consumers may use to contact these persons, as follows: 1. Check here if these persons may be contacted through your organization’s primary street address (see Item 3). Skip Item 22 and proceed to Item 23. 2. Check here if attaching individual street address information for these persons. NO. Skip Item 22 and proceed to Item 23. 22. Option 2: filing state forms: Provide all of the following information: Required Financial Information. Check here and attach either a signed and completed Department annual financial report A. form covering the preceding fiscal year, or an optional audit prepared by or with an opinion by an independent certified public accountant (see Item 23). B. Attach a list identifying your officers, directors, trustees, and salaried executive personnel, including names and street addresses (no P.O. Box addresses). C. Attach a list of the names, street addresses, and telephone numbers of the individuals or officers who have final responsibility for the custody and distribution of contributions. D. Attach a description of your organization’s major program activities. 23. Optional Audit Submission: Check here if attaching an audit: 24. Amount of G.S. §131F-2(5) contributions received in last fiscal year: CSL Contact Information: Agency Internet Site: www.sosnc.com Electronic Mail: csl@sosnc.com Telephone: (919) 807-2214 - Toll free for NC residents: 1-888-830-4989 Facsimile: (919) 807-2220 Mailing Address: P.O. Box 29622, Raleigh, NC 27626-0622 $______________________ Initial License Application Form for charitable or sponsor organizations Form Revision: 1 Effective Date: August 2, 2005 Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com North Carolina Department of the Secretary of State Charitable Solicitation Licensing Initial License Application Form for charitable or sponsor organizations 25. Consolidated application information: Is your organization applying as a parent group for one or more subordinate groups located in North Carolina? YES. Attach a list (as “Attachment 25”) of your subordinate groups containing, for each subordinate: (1) group’s full legal name, (2) street address for NC location, (2) contact person, (3) telephone number for NC location. NO. Proceed to Item 26. 26. License fee amount attached to this application: $______________________ 27. Federated fund-raising organization information: Is your organization or any of your subordinates a united way, united arts fund, community chest, or other federation of independent charitable organizations which have voluntarily joined together for the purpose of raising and distributing contributions and where membership does not confer operating authority and control of the individual group organization upon the federated group organization? YES. Attach a list (as “Attachment 27”) of your member agencies that complies with the following requirements: A. For each NC-CSL exempt member agency, provide the agency’s NC-CSL exemption number (if known), the agency’s name, why the agency is exempt (a statutory cite is sufficient), and the amount allocated by the applicant to the member agency during the previous fiscal year. B. For each NC-CSL licensed member agency, provide the agency’s NC-CSL license number (if known), the agency’s name, the agency address, the name of the executive in charge of the member agency, the agency’s telephone number, and the amount allocated by the applicant to the licensed member agency during the previous fiscal year. NO. Proceed to Item 28. 28. Applicant's signature: I swear or affirm that I am the treasurer or chief fiscal officer of the applicant organization, and that the information furnished in this application and all supplemental forms, reports, documents, and attachments are true and correct to the best of my knowledge under penalty of perjury. Signature: ________________________________________________________ Signer's Name (Print): _______________________________________________ Signer's Title (Print): _______________________________________________ 29. Notarization: The following is for a notary public to place you under oath and then notarize your signature: Sworn to and subscribed before me this the _________ day of ____________________ in the year of _______________. Notary Public's Signature: _______________________________________________ Notary Public's Name (Print): _______________________________________________ Date Notary Public's Commission Expires: _______________________________________________ If using a notary stamp or seal, stamp or imprint seal beside or below this line: CSL Contact Information: Agency Internet Site: www.sosnc.com Electronic Mail: csl@sosnc.com Telephone: (919) 807-2214 - Toll free for NC residents: 1-888-830-4989 Facsimile: (919) 807-2220 Mailing Address: P.O. Box 29622, Raleigh, NC 27626-0622 Initial License Application Form for charitable or sponsor organizations Form Revision: 1 Effective Date: August 2, 2005 Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com North Carolina Department of the Secretary of State Charitable Solicitation Licensing Optional applicant contact information: Contact Name: Contact Title: Internet Site Address: Electronic Mail Address: Telephone Number: Facsimile Number: Mailing Address: CSL Contact Information: Agency Internet Site: www.sosnc.com Electronic Mail: csl@sosnc.com Telephone: (919) 807-2214 - Toll free for NC residents: 1-888-830-4989 Facsimile: (919) 807-2220 Mailing Address: P.O. Box 29622, Raleigh, NC 27626-0622 Initial License Application Form for charitable or sponsor organizations Optional third party filer information: Business Name: Mailing Address: Internet Site Address: Contact Name: Contact's Electronic Mail Address: Contact’s Telephone Number: Contact's Facsimile Number: Initial License Application Form for charitable or sponsor organizations Form Revision: 1 Effective Date: August 2, 2005 Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com