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