Form 3201 (Revised 03/15) Submit to: Secretary of State Registrations Unit P.O. Box 13550 Austin, TX 78711-3550 512 475-0775 FAX: 512 475-2815 Filing Fee: $250.00 ____ New ____ Renewal 1. This space reserved for office use. Public Safety Organization, Independent Promoter, or Public Safety Publication Registration Statement (Please print or type and attach additional sheets if necessary) Registrant's Name: _____________________________________________________________ Type of organization: (Corporation, unincorporated entity, partnership, etc.) _______________________________________________________________________________ Street Address: _________________________________________________________________ Mailing Address: _______________________________________________________________ Telephone Number: (__________) _________________________________________________ 2. List below the name, street address, and telephone number of each solicitor that will solicit on behalf of the registrant. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 3. List the name, street address, and telephone number of each public safety organization, public safety publication, or fund on behalf of which all or part of the contributions will be used, or if there is no organization, publication, or fund, a statement describing the manner in which the contributions will be used. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 4. Does the registrant or fund for which the contributions are to be solicited have a charitable tax exemption under federal law? _________________ Under state law? _________________ What is the basis for the exemption? _______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 5. Give the name and public safety agency or former agency of each active and retired public safety officer who serves on the board of directors or governing body of the registering entity, if any. _______________________________________________________________________________ _______________________________________________________________________________ 6. How many members are active and retired public safety officers of the United States, this state, or a political subdivision of this state, as determined on December 31 of the year preceding the year in which the registration is made and for which the contributions are solicited, if the registering entity is a public safety organization? _______________________________________________________________________________ 7. What percentage of members are active and retired public safety officers of the United States, this state, or a political subdivision of this state, as determined on December 31 of the year preceding the year in which the registration is made and for which the contributions are solicited, if the registering entity is a public safety organization? _______________________________________________________________________________ 8. List the name of the local chapter, lodge, association, or group of licensed public safety officers of the public safety organization for which contributions are to be solicited, if the registering entity is a public safety organization. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 9. Attach a copy of the most recent tax or informational return filed with the Internal Revenue Service by the registering entity. List below the amount of funds collected during the previous year by the registering entity through solicitations of nonmembers of the public safety organization for which the funds were collected and the amount of funds that are paid as expenses to maintain the solicitation operation. Amount Collected:______________________________________________________________ Amount Paid as Expenses:_______________________________________________________ 10. 11. If known or projected, indicate below the amount of funds expected to be collected during the year of filing by the registering entity through solicitations of nonmembers described by #10 above. ______________________________________________________________________________ ______________________________________________________________________________ 12. Attach a copy of any contract or agreement between the registering entity and a solicitor. American LegalNet, Inc. www.FormsWorkFlow.com 13. If the registering entity is a public safety publication, provide the following information. (A) The total number of copies of each issue of the publication to be printed is _________________________________________________________________________. (B) The frequency of the publication is _________________________________. (C) The date and circulation of the most recent issue of the publication is ___________________________________________________________________ ___________________________________________________________________. 14. Is the registrant a resident of Texas? ___________________ If you are not a resident of this state, attach a written consent form appointing the Secretary of State as agent for service of process on the Registrant for any action pertaining to a violation of this Act. Executed this ______________ day of ___________________________, ___________. __________________________________________ _______________________________________ (Signature of Officer or Director) (Signature of Officer or Director) __________________________________________ _______________________________________ (Printed Name & Title) (Printed Name & Title) INFORMATION AND INSTRUCTIONS The document must be signed by two officers or directors of the registering entity. Return the registration/renewal form and $250 filing fee to: SECRETARY OF STATE Registrations Unit P. O. Box 13550 Austin, TX 78711-3550 ******* PLEASE NOTE - A CHANGE IN THE REGISTRANT'S STREET ADDRESS, PHONE NUMBER, OR NAME MUST BE FILED WITH THE SECRETARY OF STATE'S OFFICE WITHIN 30 DAYS AFTER THE DATE OF THAT CHANGE. A