State of Tennessee Department of State APPLICATION TO RENEW REGISTRATION OF A CHARITABLE ORGANIZATION
State of Tennessee
WARNING: False or misleading statements
Subject to maximum $5,000 civil penalty. T.C.A. §48-101-514
Department of State
APPLICATION TO RENEW REGISTRATION
Division of Charitable Solicitations and Gaming
OF A CHARITABLE ORGANIZATION
William R. Snodgrass Tennessee Tower
312 Rosa L. Parks Avenue, 8
th
Floor
Nashville, TN 37243
(615) 741-2555; Fax (615) 253-5173
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 Filing
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.
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: ______________
2. Do you solicit contributions under any other name(s)? Yes No If yes, list names used and attach the document
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:
(Contact Name / Title) ___________________________________
(Org. Name) ___________________________________________
(Address) ____________________________________________
(City) ______________ (State)__________(Zip) ______________
If mailing address has changed, please indicate:
(Contact Name) ______________________________________
(Street) _____________________________________________
(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:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Are you registering and reporting the financial activities of these organizations? Yes
No
(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 initial registration? Yes No . If yes, attach
a copy of the amendment(s).
7. Has your tax exempt status been revoked by the Internal Revenue Service since your last registration? Yes No
OFFICE USE ONLY
Reg. No.
Date Rec'd.
Registration
Expiration
Date:
Fee Pd.
Rec. No.
Print Form
8. Is the organization registered in any other state?
Yes No If yes, attach a list of other states.
9. Have you been enjoined by any court from soliciting contributions since your last registration? Yes No If 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 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
Print Name
_________________________________ __________________________________
Title
Title
____________________________________ _____________________________________
Date
Date
SS-6007 (Rev 3/09)
RDA 1745