VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES OFFICE OF CHARITABLE AND REGULATORY PROGRAMS PO Box 526, Richmond, VA 23218-0526 Phone: 804-786-1343 � FAX: 804-225-2666 � www.vdacs.virginia.gov OCRP-102 Revised 10/12 REMITTANCE FORM CHARITABLE ORGANIZATION FORM 102 YOU MUST USE THIS FORM TO RECEIVE PROPER CREDIT OF YOUR FEE(S) Organization name: Address: Federal Employer Identification Number: Charitable Organization Initial Registration Fee ($100): Late Registration Fee ($100): Annual Registration Fee: (See pg. 5 of Form 102) Total Fees: To assist us in tracking your payment, please enter your Check Number: $ $ $ (910-02184) (910-02184) (910-02619) $ MAKE CHECKS PAYABLE TO "TREASURER OF VIRGINIA" The Code of Virginia authorizes state agencies to assess interest, administrative charges and penalty fees for returned checks and past-due accounts in accordance with guidelines promulgated by the Department of Accounts. PLEASE ATTACH COMPLETED REMITTANCE FORM TO FRONT OF REGISTRATION FORM WITH CHECK ATTACHED AND MAIL TO: Virginia Department of Agriculture and Consumer Services PO Box 526 Richmond, VA 23218-0526 American LegalNet, Inc. www.FormsWorkFlow.com VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES OFFICE OF CHARITABLE AND REGULATORY PROGRAMS PO Box 526, Richmond, VA 23218-0526 Phone: 804-786-1343 � FAX: 804-225-2666 � www.vdacs.virginia.gov OCRP-102 Revised 10/12 REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION FORM 102 Please choose ("") the type of registration: Initial Registration Annual Renewal Unless otherwise noted, all information provided on this form and attachments must be for the CURRENT fiscal year. Financial reports (except budgets) will be for the most recently completed fiscal year. Any change in information filed must be submitted to OCA within 7 days of the change. Failure to properly complete this form or to submit all additional documentation required by any applicable section of the Rules Governing the Solicitation of Contributions will result in an ineffective registration. Your organization may not solicit in the Commonwealth of Virginia until it is properly registered. 1. Organization's primary name: 2. List any other names under which you may solicit contributions in Virginia: 3. Primary address: City State Zip Code 4. Mailing address if different from primary address above: City State Telephone, including area code Internet URL Zip Code 5. Other contact information: Fax, including area code Organization's official e-mail address* *The Official E-mail address entered above will be used for the notifications unless alternate email preference is indicated here: American LegalNet, Inc. www.FormsWorkFlow.com REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Form 102, Page 2 Revised 10/12 6. Locations of other chapters, branches, affiliates ("affiliates"): a) Does the organization have any chapters, branches or affiliates in Virginia? If "Yes," i) ii) Yes No Attach a list of the affiliates' names, addresses and telephone numbers. Are the income and expenses of these affiliates included in your organization's financial statement? Yes No If "Yes," a joint registration may be issued to the parent organization which would apply to those subordinate organizations whose finances are reported jointly with the parent organization. b) Does the organization maintain any other offices in Virginia, other than local chapters, branches or affiliates? Yes 7. Please "" one: "" No If "Yes," attach a list of the addresses and telephone numbers for those offices. Type of organization Corporation or limited liability entity Partnership Other (specify: 8. Date of incorporation or formation: 9. In what city was the organization legally established? City 10. What is the main purpose of the charitable organization? State 11. Name and address of designated agent for receipt of process within the Commonwealth of Virginia. NOTE: If no agent is designated, the organization shall be deemed to have designated the Secretary of the Commonwealth. Name and Company Name Address City 12. Organization's fiscal year: a) Dates of the CURRENT fiscal year: From: b) Has the organization recently changed its fiscal year? If "Yes," provides the dates of the "short" fiscal year: From: To: Yes No Yes To: No State Zip Code 13. Is the organization exempt under the Internal Revenue Code? American LegalNet, Inc. www.FormsWorkFlow.com REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Form 102, Page 3 Revised 10/12 14. Key personnel: a) Full name and title of the individuals having signatory power over the organization's funds: b) Full name and title of the individuals who approve the organization's budget: c) Has the organization, or any officer, professional fund-raiser or professional solicitor thereof, ever been convicted of a felony? Yes No If "Yes," attach a statement providing a description of the pertinent facts. 15. Percentage of fundraising expenses for the most recently completed fiscal year: a) Total amount of contributions received directly from the public: (found by adding Part VIII, lines 1a, 1b, 1c, and 1f of the IRS Form 990) b) Total spent on fundraising, including contracts with professional fund-raising counsel or professional solicitors: (found on line 25D of Part IX of the IRS Form 990) c) Percent of fundraising expenses (Line b divided by line a): d) For Federated fund-raising organizations ONLY: State the percentage withheld from a donation designated for a member agency: % % 16. Does the organization intend to solicit contributions from the public directly (including corporate grant proposals, doorto-door or telephone solicitations, special events, direct mail, etc.)? Yes No 17. Does the organization intend to have others outside the organization (e.g. volunteers, federated fund-raising organizations, etc.) conduct solicitations on its behalf? Yes No 18. For the current fiscal year, has your organization entered into an agreement or contract with any person(s) to conduct any aspects (including planning, managing, or carrying out) of a completed, current or upcoming solicitation? Yes No If "Yes," please indicate the arrangement with your agency by ""ing below: Category "" A B C Type of arrangement A bona fide, salaried officer or employee of the charitable organization or its parent organization An outside consultant or professional fundraising counsel A paid professional solicitor American LegalNet, Inc. www.FormsWorkFlow.com REGISTRATION STATEMENT FOR