Free ANNUAL FINANCIAL REPORT - South Carolina

State of South Carolina Office of the Secretary of State, Mark Hammond Public Charities Division
Mailing Address: P. O. Box 11350 Columbia, SC 29211 Phone: (803) 734-1790 Overnight Address: 1205 Pendleton St., Ste 525 Columbia, SC 29201 Fax: (803) 734-1604

INSTRUCTIONS FOR THE ANNUAL FINANCIAL REPORT FORM This form is due to our Office on the 15th day of the 5th month after the end of your fiscal year. (Organizations may submit an IRS Form 990 or 990-EZ to this Office instead.) To complete this form, first fill out the General Information section of the form. Next, complete all schedules relevant to your organization. Start with Schedule 5, and finish with the Financial Summary. Note that Schedule 1 and Activity Statements are required of all organizations. When completed, the form should be signed and dated by the Chief Executive Officer and Chief Financial Officer of the organization. There is no fee for filing this form. You may mail, overnight or fax the form to us. General Information · · · Employer's Identification Number (EIN) ­ Identification number assigned to a nonprofit by the Internal Revenue Service. "Fiscal Year Beginning" and "Fiscal Year Ending" ­ Organizations establish the dates of their fiscal year. If an organization wishes to change its fiscal year, it should contact our Office. Charity Registration Number - Number assigned to your organization by the Public Charities Division.

Schedule 5: Special Events and Fundraising Sales Use this schedule for special events like bingo games, golf tournaments, dinners, auctions and for sales of products like candy, fruit, t-shirts and concessions. Schedule 4: Contracts with Commercial Co-Venturers (CCV) Commercial Co-Venture (CCV) - any agreement between a business and a charity in which the business advertises that the sale of its goods or services will benefit a charitable organization and the price of the good or service does not exceed that normally charged. An example of a CCV -- a restaurant might advertise that for every hamburger sold, it will donate 25 cents to a particular charity. The charity should report on Schedule 1, Line 3 only its income from the event. Schedule 3: Contracts with Professional Fundraising Counsels (PFRC) Professional Fundraising Counsels (PFRC) - any individual or business which contracts with a charitable organization to plan, manage or prepare material for a fundraising campaign which the charitable organization will conduct. A Professional Fundraising Counsel, however, does NOT solicit funds. A PFRC might prepare grant proposals or plan a mailing for charitable organizations. Schedule 2: Contracts with Professional Fundraising Solicitors (PFRS) Professional Fundraising Solicitor (PFRS) - an individual or business which contracts with a charitable organization to solicit contributions for it. For example, a PFRS might call citizens or go door-to-door to ask for contributions. Bingo operators are considered professional solicitors under state law but not federal law. Information on bingo promoters should be entered on Schedule 5, Special Events and not Schedule 2. Thus, a charity which has hired a professional solicitor to conduct a special event would complete the Annual Financial Report Form in the same way as IRS Form 990 or 990-EZ. Schedule 1: Contributions Line 3 Line 5 Line 10 . Line 12 "Commercial Co-Venture" ­ See definition under Schedule 4 above. "Special Events and Fundraising Sales" ­ See definition under Schedule 5 above. "Other" ­ In this section, you may list other kinds of solicitation and the proceeds from them Federated Fundraising Agencies - a group of independent charitable organizations which have voluntarily joined together to raise and distribute contributions (i.e. United Way).

Activity Statements Required of all Organizations Financial Summary Line 1 "Direct Public Support" ­ donations received from direct mail, telephone solicitations, commercial coventures, door-to-door solicitations, special events, telethons, and sales of goods and services to raise money for charitable purposes. Donations to be entered on this line may be cash, securities, or property of marketable value. It does NOT include donated services or use of facilities. It includes membership dues if there is NO qualification for membership, i.e. Friends of the Library. "Indirect Public Support" - monies received from other charitable organizations, affiliates and federated fundraising agencies (for example, United Way). "Government Grants" - monies received from, and by application to, federal, state, or local governments. "Program Service Revenue" - monies your organization receives for providing services it was created to offer and for which it may have received tax exempt status. (Examples include admission fees to performances and registration fees for conferences. Include membership dues if there is a qualification for membership.) "Other Revenue" - monies from other sources, such as interest or dividends earned. It also includes local government allocations to volunteer fire departments. "Program Services" - monies which your organization spent directly on goods and services for its charitable programs and purposes. This does NOT include fundraising or administrative expenses, or combined fundraising/public information expenses. "Fundraising" ­ costs of soliciting donations. Include expenses in telemarketing, mailing, advertising, applying for grants, and fees of professional solicitors or counsels, except if they are involved solely with special events such as a bingo game. In those cases, use only Schedule 5, Special Events. "Management and General" - administrative costs for running the organization. Examples of such costs are accounting fees, bank charges, costs of board meetings and board insurance, post office box rent, office supplies, some or all of the salary of the executive director and his/her administrative assistants. "Fund Balances or Net Worth at the beginning of the year" ­ all of your organization's assets minus any liabilities at the beginning of the fiscal year. Such assets would include cash, certificates of deposits, stock, real estate, major equipment (like vehicles), etc. This figure should match the ending balance of your previous report, if any, filed with this Office. "Fund Balances or Net Worth at the end of the year" ­ all of your organization's assets minus any liabilities at the end of the fiscal year. Such assets would include cash, certificates of deposits, stock, real estate, major equipment (like vehicles), etc. Line 17 MUST EQUAL equal Line 20. "Assets" (as of Fiscal Year End) - Items of value owned by the organization. Assets include cash, certificates of deposits, stock, real estate, major equipment (like vehicles), etc. "Liabilities" (as of Fiscal Year End) ­ Debts owed by the organization. "Fund Balance" ­ Net Worth at the end of the fiscal year. This figure MUST EQUAL Line 17.

Line 2

Line 3

Line 4

Line 5

Lines 7a - 7d

Line 11

Line 12

Line 15

Line 17

Line 18

Line 19 Line 20 Certification

Both the chief executive officer and chief financial officer of your organization must sign the Annual Financial Report on its last page. If one person serves as both officers, then that person must sign in both places.

OFFICE OF THE SECRETARY OF STATE STATE OF SOUTH CAROLINA

ANNUAL FINANCIAL REPORT FOR CHARITABLE ORGANIZATIONS
This form, including any attachments, is a public record and a copy will be provided upon request to any interested person. Instructions for completing the form are attached at the end of the form. There is NO FEE for filing this form.

Office of the Secretary of State

Public Charities Division

P. O. Box 11350

Columbia, SC 29211

GENERAL INFORMATION
LEGAL NAME OF ORGANIZATION: ______________________________________________________________________ STREET ADDRESS OR P.O. BOX: ________________________________________________________________________ CITY, STATE, ZIP CODE: ________________________________________________________________________________ TELEPHONE (Area Code, Number, Ext.): ( _______ ) ______ - ______________ FAX: ( _____ ) _______ - ____________ EMPLOYER'S IDENTIFICATION NUMBER: ___ ___ -- ___ ___ ___ ___ ___ ___ ___ FINANCIAL REPORT FOR FISCAL YEAR BEGINNING (Month, Day, Year): _____ /_____ / _____ FISCAL YEAR ENDING (Month, Day, Year): _____/ _____/ _____

IS THIS A CHANGE IN YOUR FISCAL YEAR END DATE? CIRCLE ONE: YES / NO

CHARITY REGISTRATION NUMBER: _______________

FINANCIAL SUMMARY
This Section is required of ALL organizations. Applicable schedules should be completed before this section. Support and Revenue (Amounts Received During the Year) TOTAL 1. Direct Public Support (Transfer amount from Schedule 1, Line 11).............................................................._________________ 2. Indirect Public Support (Transfer amount from Schedule 1, Line 15) ..........................................................._________________ 3. Government Grants (Transfer amount from Schedule 1, Line 17) ................................................................._________________ 4. Program Service Revenue .............................................................................................................................._________________ 5. Other Revenue................................................................................................................................................_________________ 6. Total Support and Revenue (Add Lines 1 through 5)....................................................................................._________________ Expenses (Amounts Paid Out During the Year) 7. Program Services (List individually. Attach sheet if necessary.) a. _______________________________________________________ ......................................................._________________ b. _______________________________________________________ ......................................................._________________ c. _______________________________________________________ ......................................................._________________ d. _______________________________________________________ ......................................................._________________ 8. Total Program Activity (Add Lines 7a through 7d.) ................................................................................._________________ 9. Payments to Affiliates/Services to Affiliates.................................................................................................._________________ 10. Public Information Combined Fundraising ...................................................................................................._________________ 11. Fundraising....................................................................................................................................................._________________ 12. Management and General..............................................................................................................................._________________ 13. Total Expenses (Add Lines 8 through 12) .................................................................................................._________________ 14. Excess (Deficit) of Support and Revenue over Expenses (Line 6 minus Line 13)........................................._________________ 15. Fund Balances or Net Worth at the beginning of fiscal year.........................................................................._________________ 16. Other changes in Fund Balances or Net Worth (Attach explanation)............................................................._________________ 17. Fund Balances or Net Worth at end of fiscal year (Add Lines 14 thru 16. Line 17 must equal Line 20.)......_________________ Summary of Balance Sheet as of Fiscal Year End 18. Assets ............................................................................................................................................................._________________ 19. Liabilities ......................................................................................................................................................._________________ 20. Fund Balance (Line 18 minus Line 19. Line 20 must equal Line 17.) .........................................................._________________
Page 1 of 4 Pages

ACTIVITY STATEMENTS
This Section is required of ALL organizations. 1. Have your books/records been audited by or for any government agency/funding source this fiscal year? YES ________ NO _________ If YES, specify agency: ____________________________________________________________________. Period audited: from __________________________ to _______________________________. Does your organization allocate costs of multi-purpose activities between Program Services, Management and General, and Fundraising, i.e. Direct Mail, Telethon? YES ______ NO ______ Did your organization receive donated services or the use of materials, equipment, or facilities at no charge or at a substantially less than fair rental value? YES ______ NO _______ If YES, indicate the value: _________________. (Do NOT include this amount as support or as an expense on the Financial Summary.)

2.

3.

SCHEDULE 1: CONTRIBUTIONS
This Section is required of ALL organizations. BEFORE doing this Schedule, do Schedule 2, 3, 4 or 5 if applicable to your organization. Do NOT report donated services or facilities on this schedule. PORTION IN-KIND ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________

TOTAL

Direct Public Support
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Direct Mail................................................................................................... ________________ Telephone Solicitation Campaign................................................................ ________________ Commercial Co-Venture (Complete Schedule 4)......................................... ________________ Door-to-Door ............................................................................................... ________________ Special Events & Fundraising Sales (Complete Schedule 5) ....................... ________________ Telethons ..................................................................................................... ________________ Foundation and Trust Grants ....................................................................... ________________ Corporate and Business Grants or Sponsorships.......................................... ________________ Legacies and Bequests ................................................................................. ________________ Other (Specify): a. _____________________________________________ .................... ________________ b. _____________________________________________ .................... ________________ c. _____________________________________________ .................... ________________ d. _____________________________________________ .................... ________________ 11. Total Direct Public Support (Add Lines 1 through 10d. Then transfer amount on this line to the Financial Summary, Line 1.)................. ________________

Indirect Public Support
12. 13. 14. 15. From Federated Fundraising Agencies....................................................... ________________ From Affiliates ........................................................................................... ________________ From other Fundraising Agencies .............................................................. ________________ Total Indirect Public Support (Add Lines 12 through 14. Then transfer amount on this line to the Financial Summary, Line 2.) .............. ________________ ______________ ______________ ______________ ______________

Government Grants
16. Specify agency: a. _____________________________________________ .................... ________________ b. _____________________________________________ .................... ________________ c. _____________________________________________ .................... ________________ d. _____________________________________________ .................... ________________ Total Government Grants (Add Lines 16a through 16d. Then transfer amount on this line to the Financial Summary, Line 3.) ............... ________________ Total Contributions (Add Lines 11, 15 and 17.) ......................................... ________________ ______________ ______________ ______________ ______________ ______________ ______________

17.

18.

Page 2 of 4 Pages

SCHEDULE 2: CONTRACTS WITH PROFESSIONAL FUNDRAISING SOLICITORS (PFRS)
If your organization employed a professional solicitor during this fiscal year should you complete this schedule. (However, if the solicitor helped only with a special event like bingo, do NOT use this schedule. Use Schedule 5, instead) If insufficient room in the form below, copy this form and attach sheet.

ITEM
1. Brief Description of campaign, drive or event

EVENT

EVENT

EVENT

2. Date(s) covered 3. PFRS name and address

4. Total public donations* 5. All Payments to PFRS 6. All other fundraising expenses of the organization for each event, sale or campaign 7. Total Expenses (Line 5 plus Line 6)** 8. Net proceeds (Line 4 minus Line 7) * On Line 4, do NOT exclude monies paid to or retained by PFRS (i.e. monies reported on Line 5). All monies listed on Line 4 must be included on Schedule 1 under the section Direct Public Support. ** Total from Line 7 in this schedule must be included on Financial Summary, Line 10 or 11.

SCHEDULE 3: CONTRACTS WITH PROFESSIONAL FUNDRAISING COUNSELS (PFRC)
If your organization employed a professional counsel during this fiscal year, complete this schedule. (If the counsel helped only with a special event or fundraising sale, do NOT use this schedule. Use Schedule 5, instead.) If insufficient room in the form below, copy this form and attach sheet.

ITEM 1. Brief Description of services rendered

COUNSEL

COUNSEL

2. Date or period covered 3. PFRC name and address

4. All payments to PFRC*
* From Line 4 above, include total of all payments to PFRCs on the Financial Summary, Line 10 or 11.

TURN PAGE -- CHIEF EXECUTIVE AND CHIEF FINANCIAL OFFICERS MUST SIGN THE BACK OF THE ANNUAL FINANCIAL REPORT FORM.
Page 3 of 4 Pages

SCHEDULE 4: CONTRACTS WITH COMMERCIAL CO-VENTURERS (CCV)
Please see instructions attached. If insufficient room in the form below, copy this form and attach sheet.

ITEM 1. Brief Description of Sale or Event 2. Date or Period Covered 3. CCV Name and Address

EVENT

EVENT

EVENT

4. Brief description of financial terms and conditions of written contract 5. Has your organization received an accounting from the CCV? 6. Net proceeds to charity for each campaign or event* YES _____ NO _____ YES _____ NO _____ YES _____ NO _____

* Transfer net proceeds to the charity for all events from Line 6 above to Schedule 1, Line 3.

SCHEDULE 5: SPECIAL EVENTS & FUNDRAISING SALES
1. 2. 3. 4. 5. ITEM Description of Event/Sale Date(s) of Event/Sale Gross Receipts Direct Expenses* Adjusted Gross** EVENT EVENT EVENT

Direct Expenses mean the cost of any food, beverage, entertainment, rent and maintenance of building involved in a special event or the cost of any product or service sold. Also, include in Line 4 any taxes and any fees paid to professional fundraising counsels or solicitors who assisted with the sale or event such as a bingo game. ** Transfer Adjusted Gross to Schedule 1, Line 5, "Special Events."

*

CERTIFICATION
As required by Section 33-56-30 of the Solicitation of Charitable Funds Act, this form shall be signed by the Chief Executive Officer and the Chief Financial Officer of the charitable organization. (If one person serves as both CEO and CFO, he or she should sign in both places below.) WE CERTIFY THAT THE INFORMATION FURNISHED IN THIS STATEMENT IS TRUE AND CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF.
_______________________________________________________________________ Signature of Chief Executive Officer _______________________________________________________________________ Signature of Chief Financial Officer
X:\FORMS\EXTERNAL\Annual Financial Report Form.doc Rev. 3/6/2002

______________________________ Date ______________________________ Date
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