Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Charitable Organization Registration Statement Form. This is a Ohio form and can be use in Attorney General Office Statewide.
Loading PDF...
Tags: Charitable Organization Registration Statement, Ohio Statewide, Attorney General Office
Charitable Law Section
Office 614.466.3181
Fax 614.466.9788
150 East Gay Street, 23rd Floor
Columbus, Ohio 43215-3130
www.OhioAttorneyGeneral.gov
FOR OFFICIAL USE
REG# _________________
YEAR __________________
EXP. __________________
A.C. ___________________
CHARITABLE ORGANIZATION REGISTRATION STATEMENT
For Charitable Solicitation in the State of Ohio
(Section 1716.02, Ohio Revised Code)
This registration statement is to be completed by every charitable organization, except those
exempted under section 1716.03 of the Revised Code, that intends to solicit contributions in this state by any
means or have contributions solicited in this state on its behalf by any other person, charitable organization,
commercial co-venturer or professional solicitor, prior to engaging in any of these activities and annually
thereafter. Please answer all questions on the registration form and do not reference a federal tax
return or any other attachment. Failure to complete this form in its entirety will delay the
registration process.
This registration statement shall be re-filed on or before the fifteenth day of the fifth calendar
month after the close of each fiscal year in which the charitable organization solicited in this state, or by the
date of any applicable extension of the federal filing date, whichever is later.
Initial Registration ______
Renewal Registration ______
This registration is for tax year beginning ______________, 2 _ _ _ , and ending _______________, 2 _ _ _
If applicable, Ohio Bingo License Number _______________
Employer Identification Number ________________________
1.
______________________________________________________________________________
(Full official name of charitable organization)
2.
Does the charitable organization intend to solicit funds under any other name or names other than
the name listed on item 1 above (i.e., dba names)?
____ Yes
____ No
If yes, please list each name. Attach additional pages, if necessary.
______________________________________________________________________________
______________________________________________________________________________
3.
______________________________________________________________________________
(Address of principal place of business)
______________________________________________________________________________
(City)
(State)
(Zip)
(Telephone No.)
4.
E-mail address ________________________ Web address _______________________________
American LegalNet, Inc.
www.FormsWorkFlow.com
5.
______________________________________________________________________________
(Address of primary office, chapter, branch, or affiliate located in Ohio, if the above address is not in
Ohio)
______________________________________________________________________
(City)
(State)
(Zip)
(Telephone No.)
6.
Indicate the form of the charitable organization (corporation, partnership, association or
individual).
______________________________________________________________________________
7.
Does this organization file a group federal tax return on behalf of other chapters and/or affiliates?
_____ Yes _____ No. If yes, please list the address, telephone number and EIN of every office,
chapter, branch, or affiliate of this organization which is located in this state. Attach additional
pages, if necessary.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
8.
If the charitable organization does not maintain an office in this state, complete the following
information for the person that has custody of its financial records:
______________________________________________________________________________
(Name of person with custody of financial records)
______________________________________________________________________________
(Address)
______________________________________________________________________________
(City)
(State)
(Zip)
(Daytime Telephone No.)
9.
With the initial registration only, state the place where and the date when the charitable
organization, if other than an individual, was legally established:
______________________________________________________________________________
10.
With the initial registration only, please attach a copy of the charitable organization’s current
charter, articles of incorporation, agreement of association, instrument of trust, constitution, or other
organizational instrument and a copy of its regulations or bylaws.
10a.
With the renewal registration, attach a copy of any amendment to these documents.
11.
Is the charitable organization exempt from federal taxation?
___Yes
___No
If yes, under what section of the Internal Revenue Code? _________________________________
12.
With the initial registration only, please attach a copy of the charitable organization’s federal tax
exemption determination letter.
Revised: 2/24/2011
2 of 7
American LegalNet, Inc.
www.FormsWorkFlow.com
13.
Give the date of the fiscal year end for the organization:
______________________________________________________________________________
14.
Please attach a copy of the annual financial report on the form prescribed by the Attorney General
or a copy of the federal tax form as filed with the Internal Revenue Service for the immediately
preceding fiscal year as required under section 1716.04, Revised Code.
15.
Provide the names and addresses of all officers, directors, trustees, and executive personnel of the
charitable organization. Attach additional pages, if necessary:
Name
Address
Title/Position
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
16.
Give the general purposes for which the organization was created:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
17.
Please attach a schedule of the activities carried on by the charitable organization in the performance
of its purpose.
18.
State the charitable purpose(s) for which the contributions to be solicited will be used:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
19.
State the period of time during which the planned solicitation will be conducted:
______________________________________________________________________________
20.
State the counties in Ohio in which the planned solicitation will be conducted:
______________________________________________________________________________
21.
Does the charitable organization intend to solicit contributions from the public directly by using its
own resources?
___Yes
___No
22.
Does the charitable organization intend to have solicitation of contributions made on its behalf
through the use of another charitable organization, fund-raising counsel, professional solicitors, or
commercial co-venturers?
___Yes
___No
Revised: 2/24/2011
3 of 7
American LegalNet, Inc.
www.FormsWorkFlow.com
23.
Provide the names, addresses and telephone numbers of any other charitable organization, fundraising counsel, professional solicitors, and commercial co-venturers who will act on behalf of the
charitable organization and identify each by type (e.g., CO - charitable organization; FRC - fundraising counsel; PS - professional solicitors; CCV - commercial co-venturers). Attach additional
pages, if necessary.
______________________________________________________________________________
Name
Type (CO, FRC, PS, CCV)
______________________________________________________________________________
Address
Daytime Telephone No.
______________________________________________________________________________
Name
Type (CO, FRC, PS, CCV)
______________________________________________________________________________
Address
Daytime Telephone No.
24.
Please state the specific terms of the arrangements with other charitable organizations, fund-raising
counsel, professional solicitors, and commercial co-venturers for the following (attach additional
pages, if necessary):
a.
b.
Bonuses ________________________________________________________________
c.
Commissions ____________________________________________________________
d.
Expenses ________________________________________________________________
e.
25.
Salaries _________________________________________________________________
Other remunerations _______________________________________________________
Provide the names, addresses, and telephone numbers of the persons within the charitable
organization that will have final responsibility for the custody of the contributions:
Name
Addresses
Daytime Telephone No.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
26.
Provide the names of the persons within the charitable organization that will be responsible for the
final distribution of the contributions:
______________________________________________________________________________
______________________________________________________________________________
Revised: 2/24/2011
4 of 7
American LegalNet, Inc.
www.FormsWorkFlow.com
27.
Is the organization registered with or otherwise authorized by any other governmental authority in
this state or another state to solicit contributions?
___Yes
___No
If yes, please list the names and addresses of all such agencies. Attach additional pages, if necessary:
Name
Address
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
28.
Has this organization:
A.
B.
C.
D.
Been enjoined or otherwise prohibited by a government authority/court from
soliciting?
___Yes
___No
Had its registration or authority denied, suspended, revoked or enjoined by any court
or other governmental authority in this State or another State? ___Yes
___No
Entered into a voluntary agreement of compliance or assurance of discontinuance
with any government authority or in a case before a court or administrative agency?
___Yes
___No
Been issued or received a cease and desist order from any State or other governmental
authority?
___Yes
___No
If “yes” to 28A, B, C, or D, then attach explanation.
29.
Please indicate the amount of contributions received from persons in Ohio for the preceding fiscal
year (this amount should include bingo gross receipts). $__________________________________
30.
For National Organizations or soliciting organizations not located in the State of Ohio, please
indicate the amount of distributions to Ohio recipients $__________________________________
31. Please indicate the amount of bingo gross receipts generated in the State of Ohio
$_____________________________________________________________________________
Revised: 2/24/2011
5 of 7
American LegalNet, Inc.
www.FormsWorkFlow.com
ATTACHMENTS
With the initial registration only, provide:
____
A copy of the current charter, articles of incorporation, agreement of association, instrument of trust,
constitution, or other organizational instrument and a copy of the regulations or bylaws (Question
No. 10).
____
A copy of the federal tax exemption determination letter (Question No. 12).
With the initial and each renewal registration thereafter, provide:
____
A list setting forth the address and telephone number of every office, chapter, branch, or affiliate
located in this state (Question No. 5).
____
A copy of any amendment to the organizational instrument or bylaws which were implemented
during the immediately preceding year (Question No. 10a).
____
A copy of the annual financial report on the form prescribed by the Attorney General or a copy of
the federal tax form as filed with the Internal Revenue Service for the immediately preceding fiscal
year (Question No. 14).
____
A schedule of the activities carried on by the charitable organization in the performance of its
purpose (Question No. 17).
____
A check for the appropriate registration fee made payable to the “Treasurer of the State of Ohio”.
REGISTRATION FEE
Contributions
Fee
Less than $5,000
$5,000 but less than $25,000
$25,000 but less than $50,000
$50,000 or more
$ 0
$ 50
$100
$200
The amount of the registration fee is based on the amount of contributions received by the charitable
organization from persons in this state. If, for any reporting year, the charitable organization cannot
determine from its records the exact amount of contributions it received from persons in this state, it shall
compute the amount of the registration fee upon the estimated amount of contributions it received from
persons in this state, with the estimated amount to be explained in writing at the time the registration fee is
paid.
Revised: 2/24/2011
6 of 7
American LegalNet, Inc.
www.FormsWorkFlow.com
AFFIDAVIT
STATE OF _____________________:
SS
COUNTY OF ____________________:
I, ______________________________________, being first duly sworn say
(Please print Name)
that I am the ________________________________________________________
(Treasurer or Chief Fiscal Officer)
of ___________________________________________________________________
(Name of Charitable Organization)
and further state as follows:
1.
I am the individual who has completed the foregoing Charitable Organization Registration
Statement;
2.
I have read the foregoing Registration Statement and know the contents thereof;
3.
The same is true to the best of my knowledge and belief; and
4.
This Registration Statement is made for the purpose of complying with the provisions of Chapter
1716 of the Ohio Revised Code.
______________________________________
Signature
Sworn to and subscribed before me this ______ day of _______________, _______.
______________________________________
Notary Public
Seal
Date _____________________
Revised: 2/24/2011
7 of 7
American LegalNet, Inc.
www.FormsWorkFlow.com