State of South Carolina Office of the Secretary of State Mark Hammond Public Charities Division Mailing Address: Post Office Box 11350 Columbia, SC 29211 www.scsos.com charities@scsos.com Phone: (803) 734-1790 1205 Pendleton St., Suite 525 Columbia, SC 29201 Fax: (803) 734-1604 REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Please print clearly or type. Check one: [ ] Initial Registration FILING FEE: $50 [ ] Renewal/Update Employer’s Identification Number: ___ ___ -- ___ ___ ___ ___ ___ ___ ___ 1. Registration Number: ___________ Name of Organization ___________________________________________________________________ Other Organization Names Used __________________________________________________________ Contact Person’s Name __________________________________ Title ___________________________ Contact Person’s Mailing Address __________________________________________________________ City _________________________ County _______________________ State _____ Zip ____________ Work Phone No. ___________________ Home No. ___________________ Fax No. _________________ Contact Person’s E-mail ______________________________ Web Site ___________________________ Organization’s Fiscal Year End Date (Give month and date.) ______ / ______ Is this a change in your Fiscal Year End Date? Circle one: YES / NO 2. Purpose of this organization (attach sheet if necessary): ________________________________________ _____________________________________________________________________________________ 3. (a) Principal physical address of the organization: ______________________________________________________________________________ City _____________________ County _____________________ State ______ Zip___________ (b) Addresses of any of your organization’s offices in this State: City _____________________ County _____________________ State ______ Zip___________ City _____________________ County _____________________ State ______ Zip___________ (c) If the organization does not maintain an office, please provide the name and address of the person having custody of the organization's financial records: American LegalNet, Inc. www.USCourtForms.com ______________________________________________________________________________ ______________________________________________________________________________ 4. Give names, addresses and telephone numbers of: (a) Chief Executive Officer _______________________________________________________________ _____________________________________________________________________________________ (b) Chief Financial Officer _______________________________________________________________ _____________________________________________________________________________________ (c) Please attach list of board members including their addresses. (d) Registered Agent for Service of Process __________________________________________________ _____________________________________________________________________________________ 5. Names and addresses of any chapters, branches or affiliates of your organization in this State. (Attach list if necessary.) _____________________________________________________________________________________ 6. (a) Place and date the organization was legally established: __________________________________________________________________________________ (b) Form of organization. Check one: [ ] Public Benefit [ ] Mutual Benefit (c) Tax exempt status under the Internal Revenue Code: [ ] YES [ ] NO If "Yes," please provide copy of IRS tax exempt documentation. 7. Outside Professionals: Does your organization intend to use a professional fundraising counsel, professional solicitor, or commercial co-venturer or hire individuals to solicit? [ ] YES [ ] NO If yes, please attach a list of their names and contact information. 8. List any other governmental authority that has authorized your organization to solicit contributions. _____________________________________________________________________________________ 9. Has your organization been the subject of a legal or administrative action concerning a charitable solicitation, fundraising campaign, or campaign with a commercial co-venturer by another local, state, or federal governmental authority including, but not limited to, registration or license revocation or denial, fines, injunctions, or suspensions? [ ] YES [ ] NO If yes, please attach an explanation. Has any of the organization’s officers, directors, trustees, or board members been the subject of a criminal conviction, including guilty or nolo contendere pleas, involving any charitable solicitations act, fraud, dishonesty, or false statement in a jurisdiction within the United States? [ ] YES [ ] NO If yes, please attach an explanation. American LegalNet, Inc. www.USCourtForms.com 10. Organization's Category Enter NTEE Codes (up to three) here: ____ ____ ____ ____ , ____ ____ ____ ____ , ____ ____ ____ ____ OR check up to three boxes below that best describe your organization: A. Arts, Culture, Humanities (inc. historical) B. Educational Institutions (inc. literacy) C. Environment, Beautification (inc. gardening, outdoor education) D. Animal-Related (inc. wildlife sanctuaries) E. Health-General, Rehabilitative (inc. nursing, family planning) F. Mental Health, Crisis Intervention (inc. alcoholism, services for rape and abuse victims) G. Disease, Disorders, Medical Disciplines H. Medical Research I. Crime, Legal-Related (inc. prevention of abuse, delinquency) J. Employment, Job-Related (inc. voc. rehabilitation, unions) K. Agriculture, Food, Nutrition (inc. livestock breeding) L. Housing, Shelter (inc. senior citizen housing) M. Public Safety, Disaster Preparedness and Relief (inc. rescue squads, auto safety) N. Recreation, Sports, Leisure, Athletics (inc. social clubs, Special Olympics) O. Youth Development P. Human Services (inc. thrift stores, YMCAs and YWCAs, hearing- or sight-impaired orgs.) Q. International, Foreign Affairs, National Security (inc. cultural exchange) R. Civil Rights, Social Action, Advocacy (inc. right to life and right to die, reproductive rights) S. Community Improvement, Capacity Building (inc. neighborhood associations, service clubs, bus. development) T. Philanthropy, Volunteerism, Grant-making (inc. foundations) U. Science and Technology Research Institutes W. Public Affairs, Society Benefit (inc. Citizen participation, consumer protection, veterans' orgs, leadership development) X. Religion, Spiritual Development Y. Mutual / Membership Benefit (inc. fraternal organizations, cemeteries) Z. Unknown, Other Please Specify: ___________________________ CERTIFICATION AND FEE SECTION 33-56-30 OF THE SOUTH CAROLINA SOLICITATION OF CHARITABLE FUNDS ACT PROVIDES "THE REGISTRATION FORMS AND OTHER DOCUMENTS PRESCRIBED BY THE OFFICE OF THE SECRETARY OF STATE MUST BE SIGNED BY THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER OF THE CHARITABLE ORGANIZATION AND CERTIFIED AS TRUE. EVERY CHARITABLE ORGANIZATION WHICH SUBMITS A REGISTRATION TO THE SECRETARY OF STATE MUST PAY AN ANNUAL REGISTRATION FEE OF FIFTY DOLLARS ($50.00)." WE CERTIFY THAT THE ABOVE INFORMATION IS TRUE, CORRECT AND COMPLETE. CHIEF FINANCIAL OFFICER: CHIEF EXECUTIVE OFFICER: (Please Sign Name) (Please Sign Name) (Please Print Name) (Please Print Name) Form must be signed and accompanied by a fee of $50, checks payable to “Secretary of State.” Please attach a list of board members including their addresses. X:\Forms\External\Charities Registration Statement Rev. 2/10/05 American LegalNet, Inc. www.USCourtForms.com