Free Summary of Financial Activities - Tennessee

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State of Tennessee

W A R N ING: Fa ls e o r m i s le ad i ng s t at ement s Subject to maximum $5,000 civil penalty. T.C.A. §48-101-514

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

SUMMARY OF FINANCIAL ACTIVITIES OF A CHARITABLE ORGANIZATION

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INSTRUCTIONS: Complete this form with financial information from the most recently completed accounting year. The form must be signed by two (2) authorized officers.

Name of Organization: _____________________________________________________________________________ Address: ____________________________ City: _________________ State: _________ Zip Code ______________ Federal ID: __________________________ State ID: _________________ Telephone: _______________________ Accounting Year End: A. Has your accounting year changed? Yes _______ No ________

Gross Revenue 1. Public Contributions ..............................................................$ 2. Government grants ...............................................................$ 3. Program service revenue .......................................................$ 4. Special events and activities ..................................................$ 5. Gross sales of inventory.........................................................$ 6. Other Revenue .......................................................................$ 7. Total Revenue [add line 1 through line 6] ............................$ Expenses 8. Total Program Expenses........................................................$ 9. Direct Expenses from Special Events ....................................$ 10. Cost of goods sold..................................................................$ 11. Management and general expenses......................................$ 12. Fund raising expenses ...........................................................$ 13. Payments / services to affiliates.............................................$ 14. Total Expenses [add line 8 through line 13] ........................$ 15. Excess / Deficit for the year [line 7 minus line 14] ..............$ Changes in Net Assets or Fund balances 16. Net assets / fund balances at beginning of year ....................$ 17. Other changes in net assets or fund balances.......................$ 18. Net assets / fund balances [add line 15 through line 17] ....$ 19. Total assets ............................................................................$ 20. Total liabilities.........................................................................$ 21. Net assets / fund balances [line 19 minus line 20] ..............$

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B.

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C.

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D.

Accounting Method Used: ACCRUAL: __________________________ OTHER: _____________

CASH:________________________

SIGNATURES
I certify that the information furnished in this summary and all supplemental forms, documents and continuation sheets is true and correct to the best of my knowledge and belief.

________________________________________________ Signature of Authorized Officer ________________________________________________ Print Name ________________________________________________ Title _________________________________________________ Date

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Signature of Authorized Officer ____________________________________________________ Print Name ____________________________________________________ Title ____________________________________________________ Date

SS-6002 (Rev 3/31/09)

RDA 1745