APPLICATION FOR REGISTRATION: NHCT-1 www.doj.nh.gov/charitable INSTRUCTIONS -- PLEASE READ REGISTRATION FEE: (Upper right hand corner of application form) is $25. FEDERAL EMPLOYER ID #: This number is assigned to you by the IRS. It will also be required at the time a bank account is opened. It is obtained from the IRS by completing IRS Form SS4. PLEASE TYPE OR PRINT: Do not use script. LEGAL NAME OF ORGANIZATION: Type or print legal name EXACTLY as it appears on the governing document (Articles of Agreement, Articles of Incorporation, Constitution) of the organization. MAIL ADDRESS: This is the address where correspondence and reporting forms from this office may be received. If this address changes, notify this office promptly. LIST TRADE NAMES OR d/b/a IF ANY: List any and all that you may use when fundraising. FORM OF ORGANIZATION: If your organization was not created by a trust agreement or is not incorporated, the form of organization is “other” or “B”. A copy of the governing document and all amendments must be submitted for all three categories. If incorporated in N.H., the governing document must be filed with the Secretary of State. If the membership organization has been organized under the non-profit corporate laws of the District of Columbia (and in a few other states), and the Articles of Incorporation do not contain a provision for dissolution, the Letter of Determination issued by the IRS or IRS Form 1023 must be submitted in addition to the Articles of Incorporation. If you have amended or will, in the future, amend your Articles of Agreement or Bylaws, it is necessary that you file a copy of the amended documents with this office. NAMES, ADDRESSES, DAYTIME PHONE NUMBERS & TITLES: Furnish names and titles of all trustees, directors, and officers. The Board of Directors (trustees/directors) must 56414.doc (rev. 8/2009) American LegalNet, Inc. www.FormsWorkFlow.com have at least 5 voting members who are not of the same immediate family or related by blood or marriage. (See RSA 292:6-a) Home address is the location at which that individual could be personally contacted, i.e., NOT a P. O. Box. Daytime phone numbers are those numbers where that individual may be contacted between the hours of 8 AM and 5 PM. PROOF OF BANK ACCOUNT: A copy of the most recent bank statement showing the name of account holder and account number, or a copy of the most recent 990. CONFLICT OF INTEREST POLICY: Effective August 10, 1996, every charitable trust is required to adopt a policy pertaining to conflict of interest. (See RSA 7:19 II and attached Addendum) DISSOLUTION PROVISION: Required by the Attorney General’s Office and the IRS. IRS TAX EXEMPTION: Application for a tax-exempt status is received from the IRS by filing Form 1023 with them. Advise whether a tax-exempt status has been obtained from the IRS. If yes, furnish the NUMBER assigned under Section 501(c) and a copy of the Letter of Determination. If no, is it anticipated in the future? DATE OF FISCAL YEAR END: This date IS NOT determined by the Department of Justice. The end-of-the-month selected should be a date that is convenient and suitable for your organization. The annual report form (NHCT-2A) will be mailed to you on this date. CERTIFICATION: The ONLY acceptable signatures are those of the President and the Treasurer. Signatures of the Business Manager, Clerk, Secretary, Executive Director, Chief Financial Officer will not be accepted and the form will be returned to you for proper execution. In addition to the written signature, also type or print the name and title of the officers. 56414.doc (rev. 8/2009) American LegalNet, Inc. www.FormsWorkFlow.com OFFICE OF THE NEW HAMPSHIRE ATTORNEY GENERAL CHARITABLE TRUST UNIT 33 CAPITOL STREET CONCORD, N.H. 03301 NHCT-1 Registration Fee: $25.00 Please make check payable to: “State of New Hampshire” REGISTER OF CHARITABLE TRUSTS APPLICATION FOR REGISTRATION (Please Type or Print) 1. Legal Name of Organization: Federal Employer I.D. # ____________________ 2. Mailing Address and Website address: Contact Phone Number of Organization: __________________ List Trade Names or d/b/a, if any: 3. OUT OF STATE ORGANIZATIONS ONLY: Address of any office/resident agent in this state: 4. Form of Organization: (Select A, B, or C) A. (____) Charitable Corporation • Provide date of incorporation: ___/___/___ • Attach a copy of Articles of Incorporation and By-Laws/Amendments • Was corporation created via will or court decree? ( ) Yes ( ) No B. (____) Other Form of Organization/Association • Provide date formed: ___/___/___ • Attach copy of Articles of Agreement or other governing document C. (____) Trust • Provide date of instrument: ___/___/___ • Provide date of amendments, if any: ___/___/___ • Attach copy of trust instrument/amendments 56414.doc (rev. 8/2009) American LegalNet, Inc. www.FormsWorkFlow.com -2– 5. Attach a list of the names, home addresses (street #, city or town), daytime telephone numbers and titles of all trustees/directors (MUST BE AT LEAST 5 RSA 292:6-a) and officers of the entity. 6. Attach a copy of the most recent bank statement showing the name of account holder and account number or a copy of the organization’s most recent 990. 7. Attach a copy of the Conflict of Interest Policy currently in effect for the entity, or indicate where this requirement is addressed in the formation documents. Any changes to the conflict of interest policy must be submitted to this office. 8. Attach a copy of the Dissolution Provision currently in effect for the entity, or indicate where this requirement is addressed in the formation documents. 9. Have you applied to the IRS for a tax exemption (IRS Form 1023)? (____) Yes (_____) No • If yes, insert the number status under IRS Code: 501(c)(__) and attach a copy of the Letter of Determination (or forward a copy of same when it is received). • If no, do you plan to make application in the future? ( ) Yes ( ) No 10. Month fiscal year ends: ________________________ Month 56414.doc (rev. 8/2009) American LegalNet, Inc. www.FormsWorkFlow.com -3– This form must be signed by the President and the Treasurer. CERTIFICATION We declare under penalties for falsification in official matters (RSA 641) that we are authorized to sign this application on behalf of the above organization, we have examined the application including the attachments and to the best of our knowledge, it is true, correct and complete. __________________________________ ______________________________________ Signature of President Date __________________________________ ______________________________________ (Print or Type) Name of Officer Title __________________________________ ______________________________________ Signature of Treasurer Date __________________________________ ______________________________________ (Print or Type) Name of Officer Title 56414.doc (rev. 8/2009) American LegalNet, Inc. www.FormsWorkFlow.com ADDENDUM TO APPLICATION FOR REGISTRATION N.H. CHARITABLE TRUSTS FORM NHCT-1 The following paragraphs are SUGGESTED language only and are offered here to assist you in preparing provisions for a conflict of interest policy (#7) and dissolution (#4). CONFLICT OF INTEREST Sample 1 Any possible conflict of interest on the part of any member of the Board, officer or employee of the Corporation, shall be disclosed in writing to the Board and made a matter of record through an annual procedure and also when the interest involves a specific issue before the Board. Where the transaction involving a board member, trustee or officer exceeds five hundred dollars ($500) but is less than five thousand dollars ($5,000) in a fiscal year, a twothirds vote of the disinterested directors is required. Where the transaction involved exceeds five thousand dollars ($5,000) in a fiscal year, then a two-thirds vote of the disinterested directors and publication in the required newspaper is required. The minutes of the meeting shall reflect that a disclosure was made, the abstention from voting, and the actual vote itself. Every new member of the Board will be advised of this policy upon entering the duties of his or her office, and shall sign a statement acknowledging, understanding of and agreement to this policy. The Board will comply with all requirements of New Hampshire law in this area and the New Hampshire requirements are incorporated into and made a part of this policy statement. Sample 2 (a) Each Director, prior to taking his position on the Board, and all present Directors shall submit in writing to the Chairman of the Board a list of all businesses or other organizations of which he is an officer, director, trustee, member, owner (either as a sole proprietor or partner), shareholder , employee or agent, with which the Corporation has, or might reasonably in the future enter into, a relationship or a transaction in which the Director would have conflicting interests. The Chairman of the Board shall become familiar with the statements of all Directors in order to guide his conduct should a conflict arise. (b) At such time as any matter comes before the Board in such a way as to give rise to a conflict of interest, the affected Director shall make known the potential conflict, whether disclosed by his written statement or not, and after answering any questions that might be asked him, shall withdraw from the meeting for so long as the matter shall continue under discussion. Should the matter be brought to a vote, neither the affected Director nor any other Director with a pecuniary benefit transaction with the Corporation shall vote on it. (c) The Board will comply with all the requirements of New Hampshire law where conflicts of interest are involved, including but not limited to the requirements of a twothirds vote where the financial benefit to the director or trustee is between $500 and $5,000 56414.doc (rev. 4/2009) American LegalNet, Inc. www.FormsWorkFlow.com in a fiscal year, and to the requirement of a two-thirds vote and publication in the required newspaper where the financial benefit exceeds $5,000 in a fiscal year. The New Hampshire statutory requirements are incorporated into and made a part of this conflict policy. PROVISION FOR DISSOLUTION Sample The provisions for disposition of the corporate assets of the charity in the event of dissolution of the corporation are: Upon the dissolution of the corporation, assets shall be distributed for one or more exempt purposes within the meaning of Section 501(c)(3) of the Internal Revenue Service Code, or corresponding section of any future federal tax code, or shall be distributed to the federal government, or to a state or local government, for a public purpose. If you choose to name a specific organization to receive the assets of the organization in the event of dissolution, the receiving organization must be a like or similar one operating with the same purpose. If the specific organization is tax-exempt under IRS Code Section 501(c)(3), it must be registered with the State of New Hampshire Department of Justice. 56414.doc (rev. 4/2009) American LegalNet, Inc. www.FormsWorkFlow.com