SOUTH CAROLINA SECRETARY OF STATE PUBLIC CHARITIES DIVISION ANNUAL FINANCIAL REPORT Filing Instructions · · · Organizations who file the IRS 990-N or are not required to file with the IRS should complete this form. Please follow the instructions provided on pages 4 and 5 to complete this form. You may contact our office with any questions at 803-734-1790 or email charities@sos.sc.gov. We do not accept this filing by fax or email; you may upload this report using our online filing system at www.sos.sc.gov or mail this form to: South Carolina Secretary of State, Attn: Division of Public Charities, 1205 Pendleton St., Suite 525, Columbia, SC 29201. EIN: ___ - __________ Charity ID: ______________ ______ For the fiscal year ending __________ (mm/dd/yy) Organization's Name: _________________________________________________________________ Part I-- Fundraising Events or Contracts If your organization held any fundraising events, or used a commercial co-venturer (CCV) or professional fundraising company (PFR) during the previous fiscal year, you must report all revenue and expenses in the following table. Events include, but are not limited to, carnivals, dinners, galas, raffles, and bingo games. If you need additional space, you may list additional events on a separate sheet and include the amounts in the total revenue and expenses on this table. (A) Name of Event, CCV or PFR 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Gross Revenue (add 1B through 10B) Annual Financial Report, revised January 2017 (B) Gross Receipts & Contributions (C) Cash & Noncash Prize Expenses (D) Other Expenses (E) Total Expenses (F) Net Revenue 12. Total Expenses (add 1E through 10E) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com of 5 Part II-- Gross Revenue Organizations must report their gross receipts from all sources of revenue. 1. Fundraising events (from page 1, part I, box 11B) ................................................... __________________ 2. Fundraising activity revenue not reported on line 1.................................................. __________________ 3. Federated campaigns (such as United Way) ............................................................. __________________ 4. Membership dues ...................................................................................................... __________________ 5. Related organizations (such as related parent or national organizations) ................. __________________ 6. Government grants (from federal, state or local governments) ................................ __________________ 7. All other contributions, gifts, grants not listed above ............................................... __________________ 8. Program service revenue .......................................................................................... __________________ 9. Other income ............................................................................................................. __________________ 10. Total revenue (add lines 1 through 9) ................................................................... __________________ Part III-- Program Service Expenses Describe the organization's program accomplishments and the amount spent on each. If more space is needed you may attach an additional sheet if necessary. 11. ______________________________________________________________________ ................................................................................................................................ $__________________ 12. ______________________________________________________________________ ................................................................................................................................ $__________________ 13. Total Program Service Expenses (add lines 11 and 12) ..................................... $__________________ Part IV-- Management, General and Fundraising Expenses 14. Program expenses (from part III, line 13) ................................................................ __________________ 15. Direct expenses from fundraising events and contracts (box 12E) .......................... __________________ 16. Fundraising expenses (not included in the amount on line 15)................................. __________________ 17. Payments to related organizations ............................................................................ __________________ 18. Salaries and other compensation .............................................................................. __________________ 19. Management and general expenses .......................................................................... __________________ 20. Professional fees and other payments to independent contractors ........................... __________________ 21. Other expenses not listed above ................................................................................ __________________ 22. Total expenses (add lines 14 through 21) ............................................................. __________________ 23. Excess or (deficit) for the year (subtract line 22 from line 10) ................................ __________________ 24. Fund balances/net worth at the beginning of the fiscal year ..................................... __________________ 25. Changes in fund balances/net worth (attach explanation)......................................... __________________ 26. Fund balances/net worth at the end of the fiscal year (add lines 23 through 25) ...... __________________ Part V-- Balance Sheet 27. Total assets ............................................................................................................... __________________ 28. Total liabilities ......................................................................................................... __________________ 29. Net assets or fund balances at end of year (subtract line 28 from line 27) ....... __________________ Annual Financial Report, revised January 2017 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 Certification As required by Section 33-56-60 of the Solicitation of Charitable Funds Act, this form shall be signed by the Chief Executive Officer and the Chief Financial Officer of the charitable organization. (If one person serves as both CEO and CFO, he or she should sign in both places below.) We certify that the information furnished in this statement is true and correct to the best of our knowledge and belief. CEO/President Name : _