Free SC.pmd - Kansas

Contact Information
Kansas Secretary of State Ron Thornburgh Memorial Hall, 1st Floor 120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-4564
[email protected]
www.kssos.org


KANSAS SECRETARY OF STATE

Registration Statement for Solicitations
All information must be completed or this document will not be accepted for filing. Initial registration Renewal/update

SC
53-10

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This registration statement covers tax year end ___________________
Month Day Year

1.a. Name of organization: ____________________________________________________ b. Name/names under which it will solicit: ____________________________________________________ 2.a. Principal street address of the organization:

Please complete the form, print, sign and mail to the Kansas Secretary of State with the filing fee. Selecting 'Print' will print the form and 'Reset' will clear the entire form.

Do not write in this space

Address

City

State

Zip

b. Principal mailing address (if different) of the organization:

Address

City

State

Zip

3.a. Principal street address of any offices the organization has in Kansas:

Address

City

State

Zip

b. Principal mailing address (if different) of any offices the organization has in Kansas:

Address

City

State

Zip

4.a. Purpose for which the organization was organized: ____________________________________________________________________________________ b. Purpose for which the organization intends to solicit contributions (if different):
____________________________________________________________________________________
5. Names and mailing addresses of any subsidiary or subordinate chapters, branches or affiliates in Kansas:

Name

Address

City

State

Zip

6. Date of organization ___________________

State of organization ____________________

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7. Form of organization (trust, corporation, etc.):

______________________________________________

8. Has the organization applied for or been granted IRS tax exempt status?

Yes

No


If yes, date of application ____________________ or date of determination letter ____________________
If granted, exempt under 501(c) ____ Are contributions to the organization tax deductible?
Yes No

9. Names and addresses (street and mailing) of the following (attach additional pages if necessary): Officers: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

Directors: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

Trustees: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

Principal salaried employees: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

10. Name and address (street and mailing) of person having custody of the organization's financial records: _______________________________________________________________________________________________________

11. Names of the individuals or officers of the organization who will have responsibility for custody of contributions: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________
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12. Names of the individuals or officers of the organization who will have responsibility for the distribution of the contributions: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

13. Names of the individuals or officers of the organization who will have responsibility for the conduct of solicitation activities: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

14. Does the organization intend to solicit contributions directly?

Yes

No

15. Does the organization intend to have such solicitation done on such organization's behalf by others? If yes, name the professional fund raiser(s) the organization intends to use:

Yes

No

_______________________________________________________________________________________________________

16. Methods of solicitation used: Personal contact Volunteers Mail Internet Telephone Vendors Radio TV

Other ________________________________
Specify

17. Is this organization authorized by any other states or governmental authorities to solicit contributions?

Yes

No

If yes, give state or jurisdiction: ___________________________________________________________________________ 18. Is this organization, or has it ever been, enjoined by any court from soliciting contributions? Yes No

If yes, explain in detail: __________________________________________________________________________________ __________________________________________________________________________________ 19. Report all fund raising costs below. Also report total fund raising costs as a percentage of contributions received. If this is an initial registration statement, report anticipated costs. For fiscal year: ___________ ______ _______
Month to Day Year

List all fund raising costs - describe below:

___________ ______ _______
Month Day Year

Total fund raising costs: Total costs as a percent of contributions received: (Attach additional pages, if necessary)
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%

20.

Attach copies of the organization's federal IRS income tax returns (not including schedules listing individual contributors). If the organization does not file income tax returns, attach the financial statement prescribed by the Secretary of State (Form FS) disclosing all fiscal activities of the preceding year. If the organization received contributions exceeding $500,000 during its fiscal year, attach an audited financial
statement prepared in accordance with generally accepted accounting principles and the opinion of an independent
CPA.
This statement must be signed by two separate, authorized officers, one of whom must be the chief fiscal officer.

I declare under penalty of perjury pursuant to the laws of the state of Kansas that the foregoing is true and correct and that I have remitted the required fee.

Executed on this _________ of ___________________________, ____________ .
Day Month Year

Signature of authorized officer

Name (printed or typed)

Signature of chief fiscal officer

Name (printed or typed)

___________________________________
Phone number

Instructions
1. Submit this registration statement, along with all required attachments and a $35 registration fee. 2. Solicitation registration expires on the last day of the sixth month following the month in which the fiscal year of charitable organization ends. 3. Solicitation registration must be renewed each year. Notice: There is a $25 service fee for all returned checks.

Rev. 8/1/05 nr

K.S.A. 17-1763 4/4