Free Chr1copy1.pmd - West Virginia

Natalie E. Tennant Secretary of State Building 1, Suite 157K 1900 Kanawha Blvd. East Charleston, WV 25305-0770 [email protected] www.wvsos.com

Registration Statement of Charitable Organizations

Charities Division Tel: (304) 558-6000 Toll Free Tel: 1-866-SOS-VOTE 1-866-767-8683 Fax: (304) 558-5758 Hrs: 8:30 am - 5:00 pm ET

Are you required to register?
All charitable organizations that intend to solicit contributions from the public within West Virginia are required to file an annual registration statement with the Secretary of State unless it meets one of the exceptions below. Exceptions:
1. 2. 3. 4. 5. 6. 7. Charities intending to solicit funds of less than $25,000, but only if the charity does not have a professional fund-raising counsel/solicitor. (If charity raises more than $25,000, it must register); Accredited educational institutions and auxiliary associations, foundations and support groups responsible to the educational institute; Persons requesting funds solely for one individual specified by name when 100% of collections go to that individual; Nonprofit, charitable hospitals and licensed nursing homes; Organizations that solicit only with its participating (voting) membership; Churches or religious organizations that are an integral part of churches that are exempt from filing IRS Form 990 under provisions of 26 USC §6033; and Any person, firm, corporation or organization that holds a single fund-raising event for the benefit of a named charity that is registered.

How to register?
1. 2. 3. 4. 5. 6. Complete registration statement (or unified registration statement plus West Virginia supplement); Provide IRS Tax determination letter; Provide a copy of your most recent IRS Form 990; Provide balance sheet and financial statement audited by an independent public accountant, if your organization raised more than $100,000 from all sources except government grants and grants from private foundations. Copies of current contracts with professional fundraising counsel and professional solicitors (unless they are already on file) and documents reflecting final settlement or fiscal year statements for multiple year contracts.; Registration fees: (a) $15 if raised less than $1,000,000 (b) $50 if raised more than $1,000,000 Late fees of $25 for each month or part of a month that the registration is filed after due date. (Extensions may be requested in writing.)
FORM CHR-1 Issued by the Secretary of State, State Capitol, Charleston, WV 25305 Revised 1/08

WEST VIRGINIA REGISTRATION STATEMENT OF CHARITABLE ORGANIZATION
Registration Type: 1. 2. 3. 4. 5. 6. 7. 8. New Renewal Final Date

1

Official Name of Organization Street Address Mailing Address Phone _________________ Fax___________________ Email Principal West Virginia address if different from above Designated contact person Purpose of the organization: Name, address and responsible person of each chapter, branch or affiliate in the State, if any: Phone:

9.

Are the above chapters, branches or affiliates included in parent organization's registration?

Check one: Yes

No

10. List all names under which applicant intends to solicit if different from official name, if any: 11. State the purposes for which the contributions to be solicited will be used: 12. Place and date the organization was legally established: 13. The form of the organization (check or complete as applicable) 14a. Has the organization been determined to be tax-exempt by the Internal Revenue Service?
FORM CHR-1

Corporation Trust Other

Foundation

Unincorporated Association

Yes Type of IRS classification: 501(c)____ No
Revised 1/08

Issued by the Secretary of State, State Capitol, Charleston, WV 25305

14b. Has this exemption been denied, revoked or modified at any time?

Yes No

If yes, attach copy of letter of decision.

2

14c. Please check one or more methods of solicitation the organization anticipates using: Telephone Appeals Grant Writing Direct mail Special Events Door to Door Solicitation Combined Appeals Auction Bingo/Raffle Other

15. Names and addresses of all officers, directors, trustees and the principal salaried executive staff: [All charitable organizations must appoint an independent governing board to oversee expenditures, policies, progress and purposes.]

16.

Name and address of professional fundraising counsel and/or solicitor used for fundraising activities in West Virginia.

a. Are current contracts with professional fund-raising counsel and solictors on file with the Office of the Secretary of State as required by West Virginia law? b. Has the professional fund-raising counsel or professional solicitor registered and filed a bond with the Office of the Secretary of State as required by West Virginia Law? c. Give the location of any telephone facilities to be used in solicitation: d. Give the location and address of any mailing facility to be used in the solicitation of funds:
(Room No.) (City) (State)

Yes

No

Yes

No

(Street Address) (Zip)

(Street Address and Box Number) (City) (State) (Zip)

FORM CHR-1

Issued by the Secretary of State, State Capitol, Charleston, WV 25305

Revised 1/08

3 17. Is the organization authorized to solicit by any other state? If yes, please list four other states: Yes No

1. 2. 3. 4.

18.

Has the organization ever been enjoined by any court, or otherwise prevented by any governmental body, from soliciting contributions in any state? (If yes, explain in detail on separate sheet) Give names and a. Custodian of addresses for the financial records: chief person responsible for the following b. Custodian of duties: contributions: c. Person(s) making final distribution:

Yes

No

19.

20. 21. 22. 23.

Amount proposed to be raised in West Virginia (estimate): Actual amount of funds raised in West Virginia last fiscal year Amount disbursed for program services in West Virginia during the period covered by this report: (Please estimate -- if left blank, a $0 will be entered) Amount disbursed for program services outside West Virginia during the same period:

$ $ $ $

24. The license number of the raffle, bingo or other state permit used for fund-raising if any:

25. $

Computation of Fund-Raising Percentage
$
Fund-Raising Expenses

÷

= Income Derived From Fund-Raising Percentage

%

26.

How much did organization receive from government grants or private foundations during last year?

$

FORM CHR-1

Issued by the Secretary of State, State Capitol, Charleston, WV 25305

Revised 1/08

PRINT THIS COPY, THEN CLICK HERE TO RESET.

4
CERTIFICATION We the undersigned, being duly authorized to act on behalf of the applicant, do hereby certify that the information furnished in this registration is true and correct to the best of our knowledge, information and belief. Authorized Officer:

Date

Signature

Title

Type or Print Name of Applicant: State of , County of day of ,

Subscribed and sworn before me this

Notary Public My commission expires

Chief Fiscal Officer:

Date

Signature

Title

Type or Print Name of Applicant: State of , County of day of ,

Subscribed and sworn before me this

Notary Public My commission expires

FORM CHR-1

Issued by the Secretary of State, State Capitol, Charleston, WV 25305

Revised 1/08