SUMMARY OF FINANCIAL ACTIVITIES OF A CHARITABLE ORGANIZATION
State of Tennessee
WARNING: False or misleading statements
Subject to maximum $5,000 civil penalty. T.C.A. §48-101-514
SUMMARY OF FINANCIAL ACTIVITIES
Department of State
OF A
Division of Charitable Solicitations & Gaming
CHARITABLE ORGANIZATION
William R. Snodgrass Tennessee Tower
312 Rosa L. Parks Avenue, 8
th
Floor
Nashville, TN 37243
(615) 741-2555
FAX (615) 253-5173
________________________________________________________________________________
INSTRUCTIONS: Complete this form with financial information from the most recently completed accounting year. The
form must be signed by two (2) authorized officers.
Name of Organization: _____________________________________________________________________________
Address: ____________________________ City: _________________ State: _________ Zip Code ______________
Federal ID: __________________________ State ID: _________________ Telephone: _______________________
Accounting Year End: Has your accounting year changed? Yes _______ No ________
A. Gross
Revenue
1.
Public
Contributions ..............................................................$ _______________________________
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] ............................$ _______________________________
B. 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] ..............$ _______________________________
C.
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] ..............$ _______________________________
D.
Accounting Method Used:
CASH:________________________ ACCRUAL: __________________________
OTHER: _____________
Print Form
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
_______________________________________________
Signature of Authorized Officer
____________________________________________________
Print Name
____________________________________________________
Title
____________________________________________________
Date
SS-6002 (Rev 3/31/09)
RDA 1745