Free Registration Statement - South Carolina

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State of South Carolina Office of the Secretary of State Division of Public Charities Post Office Box 11350 Columbia, SC 29211 www.scsos.com Telephone: (803) 734-1790 Fax: (803) 734-1604 [email protected]

REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Please type or print clearly. Check one:
[ ] Initial Registration Enter Federal Employer's Identification Number: __ __ - __ __ __ __ __ __ __

Filing Fee - $50.00
[ ] Renewal/Update Charity Public ID: __________________

Legal Name of Organization _______________________________________________________________________ Doing Business As (DBA) Names ___________________________________________________________________ Former Names used by the Charity ____________________________________________________________________ Organization's Website ___________________________________________________________________________ Demographic Details Current Fiscal Year End Date (month/day/year) _______________________ Purpose for which this organization was formed: _______________________________________________________

_____________________________________________________________________________________________ Enter the state and country in which the organization was legally established, as well as the date of establishment ___________________________________________________________________________________________________ Form of organization. Check one: [ ] Corporation [ ] Association [ ] Trust [ ] LLC

Tax exempt status under the Internal Revenue Code: [ ] YES [ ] NO If "Yes," please provide copy of IRS tax exempt documentation. Is your organization currently, or has it in the past, 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 of all actions. Have 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 jursidiction within the United States? [ ] YES [ ] NO If "Yes," please attach a description and date of any such conviction. If any of the charitable organization's officers, directors, trustees or board members are related to one another by blood, marriage or adoption, please note in the following space. ___________________________________________________________________________________________________ If any of the charitable organization's officers, directors, trustees or board members are related by blood, marriage or adoption to a director or officer of a professional fundraising counsel or professional solicitor under contract with the charitable organization, please note in the following space.______________________________________________________________________________________________ Registered Agent for Service of Process (Include Name and Address [street address only] of the Registered Agent's Office) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________

Charities Registration Statement Revised May 2009

State of South Carolina Office of the Secretary of State Division of Public Charities

Post Office Box 11350 Columbia, SC 29211 www.scsos.com

Telephone: (803) 734-1790 Fax: (803) 734-1604 [email protected]

Physical Address Principal address of the organization _____________________________________________________________________ City _______________________________________________ State _____________ Zip__________________________

Charity Contact Contact Person's Name ________________________________________ Title ______________________________ Contact Person's Mailing Address ____________________________________________________________________ City ____________________________________________ State ____________ Zip_________________________ Contact Person's Phone Number (Daytime) _______________________________ Fax No._______________________ Contact Person's E-mail Address ____________________________________________________________________

CEO CEO's Name _______________________________________________ Telephone Number _______________________

CEO's Mailing Address _______________________________________________________________________________ City __________________________________________ State _______________ Zip _________________________

CFO CFO's Name _______________________________________________ Telephone Number _______________________

CFO's Mailing Address _______________________________________________________________________________ City __________________________________________ State _______________ Zip _________________________

Charity Offices in South Carolina Addresses of any of your organization's offices in this State: City ______________________________________________________State ___________ Zip______________________ City ______________________________________________________ State __________ Zip______________________ Custody 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: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________
Charities Registration Statement Revised May 2009

State of South Carolina Office of the Secretary of State Division of Public Charities

Post Office Box 11350 Columbia, SC 29211 www.scsos.com

Telephone: (803) 734-1790 Fax: (803) 734-1604 [email protected]

Charity Board Members Name _________________________________________________ Title ______________________________________

Address ____________________________________________________________ Phone __________________________ Name _________________________________________________ Title ______________________________________

Address ____________________________________________________________ Phone __________________________ Name _________________________________________________ Title ______________________________________

Address ____________________________________________________________ Phone __________________________ Name _________________________________________________ Title ______________________________________

Address ____________________________________________________________ Phone __________________________

Chapter/Branch/Affiliates Names and addresses of any chapters, branches or affiliates of your organization in this State. (Attach list if necessary.) ___________________________________________________________________________________________________

Governmental Authority Other governmental authorities that have authorized your organization to solicit contributions Enter a "1" if you are already registered, a "2" if your registration is pending and leave blank if you are not registered to solicit contributions with a particular state.
AL FL LA NC OK UT AK GA MA ND OR VA AR HI MD NE PA VT AZ IA ME NH PR WA CA ID MI NJ RI WI CO IL MN NM SC WV CT IN MO NV SD WY DC KS MS NY TN DE KY MT OH TX

If any other governmental authority that is not listed above has authorized your organization to solicit contributions, enter the name of the governmental authority ________________________________________________________________

Professional Fundraisers Contracted With If your organization intends to use professional solicitors, professional fundraising counsel, commercial co-venturers or hire individuals to solicit, please list their names, addresses, telephone numbers, and dates during which they will be engaged. Please attach a separate page if necessary. __________________________________________________________________________________________________ ___________________________________________________________________________________________________

Charities Registration Statement Revised May 2009

State of South Carolina Office of the Secretary of State Division of Public Charities

Post Office Box 11350 Columbia, SC 29211 www.scsos.com

Telephone: (803) 734-1790 Fax: (803) 734-1604 [email protected]

Charity Organization Category and Purpose Complete either Section 1 or Section 2 below which describes both the charity's category and the purpose of the charity's solicited donations. Section 1: Enter up to three NTEE (National Taxonomy of Exempt Entities) Codes here: ____ ____ ____ ____ , ____ ____ ____ ____ , ____ ____ ____ ____ Section 2: 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 (inc. computer science, engineering) V. Social Sciences Institutes (inc. institutes for studies on population, minorities and economics) W. Public Affairs, Society Benefit (inc. citizen participation, consumer protection, veterans' orgs., leadership development) X. Religion, Spiritual Development (inc. religious broadcasters and interfaith coalitions) Y. Mutual / Membership Benefit (inc. fraternal organizations, cemeteries) Z. Unknown, Other Please Specify: ___________________________

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 the giving of false or incorrect information may constitute a misdemeanor carrying a penalty upon conviction, for a first offense of not more than two thousand dollars or imprisonment for not more than one year, or both. A second, or subsequent offense is a felony and upon conviction must be fined not more than five thousand dollars or imprisoned not more than five years, or both. CHIEF FINANCIAL OFFICER: CHIEF EXECUTIVE OFFICER:

Signature

Signature

Print Name _________________________________________ Date

Print Name _____________________________________________ Date

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Filing Instructions: This form must be signed and accompanied by a fee of $50. Please make checks payable to the Secretary of State. Please return the form and fee to: South Carolina Secretary of State, Attn: Division of Public Charities, Post Office Box 11350, Columbia, SC 29211 If the annual financial report for the immediately preceeding fiscal year has not already been filed with the Secretary of State's Office, please attach the report on forms prescribed by the Secretary of State or on IRS Form 990, 990EZ or 990PF.

Charities Registration Statement Revised May 2009