Free Charitable Organization Quarterly Financial Report - Tennessee

State of Tennessee

W A R N I N G : F a l s e o r m i s l e a d i n g s t a t e m e n t s subject to maximum $5,000 civil penalty. T.C.A. §48-101-514

Date Received

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 / (615) 253-5173 - fax

QUARTERLY FINANCIAL REPORT

___________________________________________________________________
INSTRUCTIONS: A newly registered organization in its first year of operation must complete a quarterly

financial report at the end of each quarter of its current fiscal year. The report is due within thirty (30) days of the end of each quarter. _____________________________________________________________________________________

1. Organization Name: ____________________________________________________________ 2. Registration Number: _________________________ 3. Financial Period: 1st Quarter 3rd Quarter _______ _______ _______
Month Day Year

2nd Quarter 4th Quarter TO _______ _______ _______
Month Day Year

_____________________________________________________________________________________

I. REVENUE Gross Contributions: Other Revenue: Total Revenue $ ______________________ $ ______________________ $ ______________________

II. EXPENSES Program Services: Fundraising: Administrative: Other (Attach Schedule) Total Expenses $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________

_____________________________________________________________________________________

Number of continuation pages attached: _________________

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
____________________________________________

___________________________________ Signature of Authorized Officer
________________________________________

Print name ________________________________________ Title ________________________________________ Date

Print name ____________________________________ Title ____________________________________ Date

SS ­ 6039 (Rev. 5/19/09)

RDA 1742