Free Renewing Organizations - Tennessee

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State of Tennessee Department of State
Division of Charitable Solicitations and Gaming William R. Snodgrass Tennessee Tower 312 Rosa L. Parks Avenue, 8th Floor Nashville, TN 37243 (615) 741-2555; Fax (615) 253-5173

WARN ING: F a lse or mis lead ing stat e men ts Subject to maximum $5,000 civil penalty. T.C.A. §48-101-514

APPLICATION TO RENEW REGISTRATION OF A CHARITABLE ORGANIZATION

INSTRUCTIONS: Please type or print all items on this form which are applicable to your organization. If you are unable to answer in the space provided, you may attach additional sheets. Indicate that an item does not apply by placing N/A by its number. The amount of the filing fee is as follows: Organization's Gross Revenue iling Fee $0-$48,999.99 ........................................ $100.00 $49,000.00-$99,999.99 .............................. $150.00 $100,000.00-$249,999.99 ........................... $200.00 $250,000.00-$499,999.99 ........................... $250.00 $500,000.00-ABOVE ............................... $300.00 A NONREFUNDABLE registration fee must accompany this application. See REVERSE side for additional instructions.

OFFICE USE ONLY
Reg. No. Registration Expiration Date: Fee Pd. Rec. No. Date Rec'd.

1.

Name of organization:_____________________________________________________________________________ If name has changed, please indicate: ________________________________________________________________ FEIN: _____________ Accounting period end date: m/d/y ___________________ Has the accounting period changed since your last registration? Yes No If yes, please indicate: ______________

No If yes, list names used and attach the document 2. Do you solicit contributions under any other name(s)? Yes authorizing such use. 3A. Principal Office Address or Name and Address of Person Having Custody of Financial Records
(Name) _______________________________________ (Street) _____________________________________________________ (City) ________________________________________ (State) _____________________________ (Zip) ____________________

If principal address has changed from above, please indicate:
(Street)_____________________________________________________________________________________________________ (City) ________________________________________ (State) ____________________________ (Zip) _____________________ 3B.

Mailing / Contact Address:

If mailing address has changed, please indicate:
(Contact Name) ______________________________________ (Street) _____________________________________________ (City) _____________________________________________ (State) ________________________ (Zip) ________________

(Contact Name / Title) ___________________________________ (Org. Name) ___________________________________________ (Address) ____________________________________________ (City) ______________ (State)__________(Zip) ______________

4.

Telephone Number: ______________ Fax Number: _________________ Email Address:_______________________ If information in number 4 has changed, please indicate in provided area below. Telephone Number: ______________ Fax Number: _________________ Email Address:_______________________

5. Have you added any Chapters, Branches or Affiliates in Tennessee since your last registration? Yes No If yes; list name and address: _______________________________________________________________________________________________ _______________________________________________________________________________________________ No Are you registering and reporting the financial activities of these organizations? Yes (NOTE: a chapter, branch, or affiliate that solicits or receives contributions from any source other than the parent organization or a governmental agency must register independently and pay its own filing fee) 6. Have you amended the organizational documents submitted with your last registration? Yes a copy of the amendment(s). 7. No . If yes, attach No

Has your tax exempt status been revoked by the Internal Revenue Service since your last registration? Yes

8. Is the organization registered in any other state?

Yes

No

If yes, attach a list of other states. No If yes,

9. Have you been enjoined by any court from soliciting contributions since your last registration? Yes attach copy of court order.

10. Attach a list of the name, title, and address of each officer, director, and trustee. (list principal salaried officer first) 11. List the name and address of individual(s) who have final responsibility for the custody of contributions:
(Name) (Street) (City) (State) (Zip) _________

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

13. Has any officer, director, manager, operator or principal been the subject of an injunction, judgment or administrative order or been convicted of a felony? Yes No If yes, attach copy of court order. 14. Describe the purpose of the organization: _______________________________________________________________________________________________ _______________________________________________________________________________________________ 15. 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.

__________________________________________________________________________________ SIGNATURE SECTION
This document must be signed by two authorized officers, one of whom shall be the Chief Fiscal Officer. I certify that the state ments in thi s registration statement and all sup plemental forms, documents and continuation sheets are true and correct to the best of my knowledge and belief.

_________________________________
Signature of Authorized Officer Print Name Title

__________________________________
Signature of Authorized Officer Print Name Title

_________________________________ _________________________________
____________________________________ Date

__________________________________ __________________________________
_____________________________________ Date

SS-6007 (Rev 3/09)

RDA 1745