Page 1 of 3 North Carolina Department of the Secretary of State Solicitation License Application Charitable Solicitation Licensing Division Charitable or Sponsor Organization PO Box 29622 REVISED FEBRUARY 15, 2018 Raleigh, NC 27626-0622 Phone: 919-814-5400 NC only Toll Free: 1-888-830-4989 Email: csl@sosnc.gov Website: www.sosnc.gov If applicant received less than $25,000 in N.C.G.S. 247131F-2(5) contributions in immediate preceding fiscal year and does not compensate any officer, trustee, organizer, incorporator, fundraiser, or solicitor, applicant may be eligible for exemption and may file 223Request for Exemption Under 131F-3(3)224 and submit supporting documentation. This Form is available at https://www.sosnc.gov/forms/bytitle/CharitiesCharitiesSponsors and may be filed in lieu of the application. 1. Check appropriate box: Initial Application Renewal Application 2. N.C. Charitable Solicitation License Number: (renewal applicants only) 3. Legal Name of Applicant Organization: 4. Principal Street Address: 5. City: State: Zip Code: 6. Mailing address (may not be third party filer): 7. Telephone number: 8. Email address (may not be third party filer): 9. Applicant222s Website: 10. List all other NC locations: Street address(es): Telephone number(s): 11. Charitable purpose for which applicant is organized: 12. Charitable purpose for which solicited contributions will be used: 13. Major program activities of applicant: 14. Applicant222s Fiscal Year End Date: (month/day) 15. Has applicant received a federal tax exemption determination letter? Yes No IRS Tax Exemption Code: (e.g. 501(c)(3) or other code included on IRS Tax Exempt Determination letter) If yes, applicant must provide a copy of their 223IRS Tax Exempt Determination224 letter to the Department with this application or upon receipt to obtain a tax exempt license. Once submitted, the Department will keep the applicant222s letter on file. 16. Applicant222s State of Establishment: Applicant222s Date of Establishment: For non-NC corporations: Provide either of the following to verify the applicant222s current legal existence: 1. Certificate of Existence or Certificate of Good Standing from state of incorporation dated no more than six months prior to date of signing of application, or 2. Actual webpage screenshot found on a publicly accessible regulatory authority website dated no more than thirty (30) days prior to the date the license application was signed that includes the following elements: Exact name of the entity as it appears on the license application; and Language clearly verifying its status as a corporation in good standing in the state of incorporation (i.e. 223current224 or 223active224); and Date the information was printed on the face of the document. For un-incorporated NC applicants: Provide a copy of your assumed name certificate filed with the register of deeds, showing the register of deeds222 stamp. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 The following items MUST be included with your application package: PLEASE ATTACH 17. List of all names used by applicant in the solicitation of contributions. All names must be legally registered and documentation of legal registration of all names in state where registered must be filed with application. 18. List of all states where applicant is authorized to solicit contributions (other than NC) 19. List of names and street addresses of directors, officers, trustees, and salaried executive personnel for current fiscal year. (The applicant222s street address may be used.) 20. List of names of individuals or officers in charge of any solicitation activities. 21. List of names, street addresses, and telephone numbers of individuals or officers who have final responsibility for custody and/or final distribution of contributions. 22. Name, street address, and telephone number of individual who has custody of applicant222s financial records (if applicant does not maintain an office in North Carolina). 23. Financial information: Include with the application at least one of the following documents with financial information for the immediate preceding fiscal year. Check all documents that are included with this application. IRS Form 990 or 990-EZ (with dated signature of authorized official) Audited Financial Statement NC Annual Financial Report Form Note: Schedule A is required with the Form 990 (available at https://www.sosnc.gov/forms/bytitle/CharitiesCharitiesSponsors) Note: IRS e-postcard (Form 990-N) is not sufficient to satisfy the financial information requirement. For newly established applicants with no financial history, a proposed budget for the current fiscal year including projected revenues and expenses must be submitted. 24. Contract(s) information: Does applicant intend to enter into, presently have, or had within the last 12-month period a contract(s) with any person who qualifies as a fundraising consultant, solicitor, or coventurer? Yes, intend to enter or presently have Yes, had an active contract within the last 12 months No If yes, for EACH applicable Contractual Agreement or active contract within the last 12 months, attach a completed NC Fundraising Disclosure Form. (available at https://www.sosnc.gov/forms/bytitle/CharitiesCharitiesSponsors) 25. Consolidated Application information: Is applicant applying as a parent organization for one or more subordinate organization(s) (chapter, branch, member or affiliate) located in North Carolina? Yes. No. If yes, attach a list of applicant222s subordinate organization(s), include for each subordinate: (1) organization222s full legal name, (2) for non-incorporated applicants, copy of stamped certificate of 223doing business as224 or 223assumed name224 filed with local Register of Deeds), (3) address for each NC location, (4) contact person for each NC location, and (5) telephone number for each NC location. If yes, attach appropriate parent and subordinate organization(s) financial information in accordance with instructions in Question 23. 26. Federated Fundraising Organization information: Is applicant 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. No. If yes, attach a list of applicant222s member agencies that complies with the following requirements: A. For each NC member agency exempt from license requirements, the agency name, why the agency is exempt (a statutory cite is sufficient), and the amount allocated by the applicant to the member agency during the immediate preceding fiscal year. B. For each NC member agency subject to license requirements, provide the agency222s charitable solicitation license number assigned by the Department, the agency name, the agency address, the name of the executive in charge of the member agency, the agency telephone number, and the amount allocated by the applicant to the licensed member agency during the immediate preceding fiscal year. 27. Does applicant compensate (in any capacity) any officer, trustee, organizer, or incorporator? Yes. No. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 28. Has applicant or any of its officers, directors, trustees, or salaried executive personnel been enjoined from soliciting contributions in any jurisdiction? Yes. No. If Yes, attach an explanatory statement. 29. Has applicant or any of its 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 in any jurisdiction? Yes. No. If Yes, attach an explanatory statement. 30. Has applicant had its authority denied, suspended, or revoked by any governmental agency? Yes. No. If yes, attach an explanatory statement including the reason(s) for each denial, suspension, or revocation. 31. Has applicant entered into any assurance of voluntary compliance or similar agreement in any juris