EXEMPT ORGANIZATION FUND-RAISING NOTICE OFFICE OF THE SECRETARY OF STATE STATE HOUSE ANNAPOLIS, MD 21401 410-974-5534
http://www.sos.state.md.us NEW RENEWAL
Print this form, complete it and mail to: Charitable Organizations Division, Office of the Secretary of State, State House, Annapolis, Maryland 21401 For assistance, call: (410) 974-5534 or e-mail your question to us. The Exempt Organization Fund-Raising Notice is required for charitable organizations that raise less than $25,000 in charitable contributions or solicit contributions for a named individual and the gross amount is delivered to the individual. 1. Name of Charitable Organization or Name of Individual for whom the fund-raising campaign is being conducted. ______________________________________________________________________ 2. Employer I.D. Number of Charitable Organization or Social Security Number of Individual _______________________ 3. Street Address ____________________________________________________________________ 4. City, State & Zip __________________________________________________________________ 5. County ________________________ 6. Telephone Number _______________ 7. FAX Number _______________
8. E-mail address (if applicable) ________________________________________________________ 9. Purpose of Charitable Organization or Charitable Fund-raising _______________________________________________________________________________ 10. Have you received 501(c)(3) status from IRS? Check one: Yes No Pending
If yes, please submit a copy of your organization's tax determination letter issued by the Internal Revenue Service. 11. Methods of Fund-raising (check all that apply). Mail Telephone Canisters Door-to-Door Other (describe below)
12. Fund-raising Start Date _______________________________________________________ 13. Name and address of individual with custody of financial records __________________________________________________________________________ 14. Names and addresses of persons with final responsibility for custody and final distribution of contributions ________________________________________________________________ ___________________________________________________________________________ 15. Bank name, address, and account number, where contributions are deposited ___________________________________________________________________________ 16. Check One: This organization is exempt from registering as a charitable organization because it solicits contributions for a named individual and the gross amount is delivered to the individual. Business Regulation Section 6-102(c)(1)(ii)(1), or This organization is exempt from registering as a charitable organization because it has not to date received more than $25,000 in charitable contributions during the most recently completed fiscal year ending _________ . Business Regulation Section 6-102(c)(1)(ii)(4). 17. If your organization files with the Internal Revenue Service an IRS Form 990 or 990 EZ, please submit with this notice a copy of the IRS Form 990 or 990-EZ for the most recently completed fiscal year. If your organization does not file either an IRS Form 990 or 990 EZ, please answer the following questions: A. Amount of contributions received in most recently completed fiscal year __________ B. Amount of contributions received to date in current fiscal year __________ 18. Is organization a private foundation that is affiliated with any Maryland State agency? Yes No (If yes and raised more than $100,00) you must submit an Audit and Agreed Upon Procedures Report with application.
I do solemnly affirm under the penalties of perjury that the contents of this document are true to the best of my knowledge, information, or belief. (Type or Print) Name of Individual or Chief Executive Officer of Organization __________________________________________________________________ __________________________________________________________________ Signature Date