Free New Organizations - Tennessee

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State of Tennessee

WARNING: False or misleading statements Subject to maximum $5,000 civil penalty. T.C.A. §48-101-514

Office Use Only Reg. No.

Fee Paid

Department of State

Division of Charitable Solicitations and Gaming Rec. No. William R. Snodgrass Tennessee Tower 312 Rosa L. Parks Avenue, 8th Floor Nashville, TN 37243 (615) 741-2555; Fax (615) 253-5173 _________________________________________________________________________________________________________________________________________

APPLICATION FOR REGISTRATION OF A CHARITABLE ORGANIZATION

INSTRUCTIONS: Please type or print all applicable items. If you are unable to answer in the space, attach additional sheets. Indicate that an item does not apply by placing N/A by its number. A NONREFUNDABLE registration fee of $50.00 must accompany this application. If an organization is renewing its application, please complete form SS-6007, Application to Renew Registration of a Charitable Organization.
___________________________________________________________________________________________________________________________

1. Name of organization: _____________________________________________________________________________ The name of the organization should be the legal name as stated in the organization's organizing instrument (i.e., articles of incorporation, by laws, etc.) 2. Federal Employer Identification Number: ______________________________________________________________ All organizations must apply for a Federal Employer Identification Number from the Internal Revenue Service, including organizations that have a group exemption or file group returns. 3. Principal Office Address or, if no office is maintained, Name, Address of Person Having Custody of Financial Records: _______________________________________________________________________________________________
Name Street City State Zip

4. Mailing / Contact Address, if different from principal office: (Contact Name / Title) __________________________________ _______________________________________________________________________________________________
Name Street City State Zip

5.

Telephone Number: ____________________ Fax Number: __________________ Email: ______________________

6. A. Do you solicit contributions under any other name(s)? Yes No If yes, list name below: ____________________________________________________________________________________________ B. Attach copies of documents authorizing your solicitation of contributions under the name(s) shown above. 7. Has any officer, manager, director, operator, or principal of the organization ever been the subject of an injunction, judgment, or administrative order or been convicted of a felony? Yes No If yes, attach a detailed explanation. 8. A. Attach a list of the name, title, and address for all officers, trustees, and directors of the organization. (List principle salaried officers first.) 9. Describe the purpose of the organization: ______________________________________________________________ _______________________________________________________________________________________________ 10. A. Legal entity of organization: Corporation Partnership Association Other (specify) B. When and where was the organization legally established? Date: ________ City:____________ State: ________ C. Beginning and ending dates of the organization's accounting period: (m/d) __________ to (m/d) ___________ 11. A. If the organization is a corporation, attach the charter or similar document. If the organization is not a corporation, attach a copy of the bylaws. B. Attach a copy of any amendments to the above. 12. A. Is the organization recognized by the Internal Revenue Service as tax exempt? Yes (Attach a copy of the determination letter) No B. If no, has the organization applied for tax exempt status? Yes No If yes, attach a copy of the completed application(IRS form 1023) and any letters received from the IRS acknowledging receipt.

13. List all chapters, branches, and affiliates of the organization located in Tennessee and indicate whether you are reporting the financial activities of this organization. Name of chapter, branch, affiliate Address Reporting financial activity? ______________________________________________________________________ Yes No 14. Is the organization currently registered in any other state? Yes No If yes, attach a list of other states. Yes No

15. Has the organization ever been enjoined or prohibited by any court from soliciting contributions? If yes, attach a detailed explanation.

16. List the name and address of individual(s) who have final responsibility for the custody of contributions: _______________________________________________________________________________________________
Name Street City State Zip

17. List the name and address of individual(s) who have responsibility for the final distribution of contributions: _______________________________________________________________________________________________
Name Street City State Zip

18. If your organization contracts with or otherwise engages the services of any outside fundraising professional (such as a "professional fundraiser," "paid solicitor," "fund raising counsel," or "commercial co-venturer"), attach a list including their names, addresses (street and P.O.), telephone numbers, and location of offices used by them to perform work on behalf of your organization. Additionally, submit a true copy of any contract with the listed entity. 19. For what purpose will the organization use the contributions? (be specific) ____________________________________ _______________________________________________________________________________________________

___________________________________________________________________________________ Signature Section
This document must be signed by two authorized officers. I certify that the statements in this registration statement and all supplemental forms, documents and continuation sheets are true and correct to the best of my knowledge and belief. _____________________________________ Signature of Authorized Officer _____________________________________ Print Name _____________________________________ Title _____________________________________ Date _____________________________________ Signature of Authorized Officer _____________________________________ Print Name _____________________________________ Title _____________________________________ Date

SS-6001 (Rev 3/09)

RDA 1745