Annual Raffle Registration Form --Revised May 2016 Page 1 of 4 SOUTH CAROLINA SECRETARY OF STATE PUBLIC CHARITIES DIVISION ANNUAL RAFFLE REGISTRATION FORM Filing Instructions & Information Upon acceptance of this registration form, the applicant organization will be issued a letter confirming that it has registered with the Secretary of State for the purpose of conducting nonprofit raffles as provided under S.C. Code of Laws 247247 33-57-100, et. seq. This letter will be sent via email to the contact person listed below. Once accepted, this raffle registration shall expire on the 15th day of the 5th month, or 4 275 months, after the end of the st to December 31st, this registration will expire on May 15thst to June 30th, this registration will expire on November 15th. We do not accept this filing by fax or email; you may register using our online filing system at www.sos.sc.gov , or you may mail this form to South Carolina Secretary of State, Attn: Division of Public Charities, 1205 Pendleton St., Suite 525, Columbia, SC 29201. This registration form must be accompanied by a filing fee of $50.00 made payable to the Secretary of State. Please type or print clearly. You may attach additional pages as necessary. Please contact our office with any questions at 803-734-1790 or charities@sos.sc.gov . Check one: [ ] Initial Registration [ ] Renewal Current Fiscal Year Dates to (mo/day/year) (mo/day/year) - Raffle Registration ID: (Renewal only) 1. Legal Name of Organization: a. Doing Business As (DBA) Names: (If applicable) b. Former Names Used by the Charity: (If applicable) c. : (If applicable) d. Please provide a contact person for this organization: Name Title Address, City, State, Zip Code Daytime Phone Email 2. Please describe the purpose for which this organization is organized and operated: American LegalNet, Inc. www.FormsWorkFlow.com Annual Raffle Registration Form --Revised May 2016 Page 2 of 4 3. a. Is this organization recognized by the South Carolina Department of Revenue and the United States Internal Revenue Service as exempt from federal and state income taxation pursuant to the Internal Revenue Code? [ ] YES [ ] NO b. to question 3a, please indicate the Internal Revenue Code section under which the organization is exempt, and attach a copy of the determination letter - exempt status from the Internal Revenue Service, along with any changes, amendments or revocations to that letter, to this registration form: [ ] 501(c)(3) [ ] 501(c)(4) [ ] 501(c)(6) [ ] 501(c)(7) [ ] 501(c)(8) [ ] 501(c)(10) [ ] 501(c)(19) [ ] 501(d) [ ] Other 4. a. Is this organization a class, department, or organization of an educational institution? [ ] YES [ ] NO b. 4a, provide the name of the educational institution: 5. a. Is this organization currently registered as a charitable organization with the Secretary of State, or has this organiztion filed an annual application for registration exemption with the the Secretary of State, in compliance with the South Carolina Solicitation of Charitable Funds Act? [ ] YES [ ] NO b. c. Ifiling requirements of the South Carolina Solicitation of Charitable Funds Act: [ ] The organization is a church, synagogue, mosque or other house of worship. [ ] Other 6. a. Enter the state and country in which the organization was legally established, as well as the date of establishment: State Country Date (mo/day/year) b. Form of organization: [ ] Corporation [ ] Unincorporated Association [ ] Other c. If the organization is a corporation, provide the name and street address of its registered agent. Name (This cannot be the name of the organization.) Street Address (PO Box cannot be accepted.) City State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com Annual Raffle Registration Form --Revised May 2016 Page 3 of 4 7. Complete a or b, whichever applies: a. Physical address of the organization: Street Address (PO Box cannot be accepted.) City State Zip Code b. If the organization does not maintain an office, please provide the name and address of the person having physical custody of the organization's financial records: Name Street Address (PO Box cannot be accepted.) City State Zip Code 8. Addresses of any of this offices in South Carolina. Attach a list if necessary. Name Address, City, State, Zip Code 9. Names and addresses of any chapters, branches or affiliates of this organization in South Carolina. Attach a list if necessary. Name Address, City, State, Zip Code 10. For the current fiscal year, please provide the names and addresses of this organization officers, directors, trustees, and board members. Attach a list if necessary. Name Address, City, State, Zip Code Title Name Address, City, State, Zip Code Title Name Address, City, State, Zip Code Title Name Address, City, State, Zip Code Title 11. a. Have any of the directors been the subject of a criminal conviction under S.C. Code 247 33-57-170, including the offenses of conducting a nonprofit raffle in violation of the statutorty provisions governing raffle registration; violating the statutory provisions governing raffles with the intent to deceive or a raffle registration or financial report? [ ] YES [ ] NO b. If to question 11a, provide the date and description of any such conviction as well as the name of the person convicted. Attach a list if necessary. American LegalNet, Inc. www.FormsWorkFlow.com Annual Raffle Registration Form --Revised May 2016 Page 4 of 4 I certify that the information furnished in this application and all attached supplementary information is true and correct to the best of my knowledge, information and belief. I understand that the giving of false or misleading information may constitute a misdemeanor carrying a penalty upon conviction of a fine of not more than two thousand dollars or imprisonment for not more than one year, or both, for a first offense. A second or subsequent offense may constitute a felony carrying a penalty upon conviction of a fine of not more than five thousand dollars or imprisonment of not more than five years, or both. CHIEF FINANCIAL OFFICER / TREASURER CHIEF EXECUTIVE OFFICER / PRESIDENT Print Name Print Name Signature Date Signature Date Mailing Address Mailing Address City, State, Zip City, State, Zip Phone Number Phone Number * The persons signing this form as CEO/President and CFO/Treasurer must be designated as such on the current list of officers, directors, trustees, and board members. If not, the registration will be returned for correction. American LegalNet, Inc. www.FormsWorkFlow.com