Title 9 . Law

Chapter 12 . Executive Branch Code of Ethics

Section 10. Charitable organizations: registration statement

9 AAC 12.010. Charitable organizations: registration statement

A charitable organization shall submit a registration statement to the department on the following form:

Return to: Alaska Department of Law Fair Business Practices Section CHARITABLE ORGANIZATION REGISTRATION STATEMENT This form must be filed on or before September 1 as required by AS 45.68.010 . 1. Name of charitable organization _______________________________________ 2. Mailing address _____________________________________________________________________________ _____________________________________________________________________________ City State (or country) Zip 3. Street address (if different) ___________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ City State (or country) Zip 4. Daytime phone ( ) ____-_____________ 5. Is the charitable organization a corporation? Yes ( ) No ( ) Year incorporated: ____________ year founded: _______________________________ (if different) State (or country) of incorporation: ________________________________________ 6. Purpose of organization: [ ] School, college, and other training [ ] Cultural and historical [ ] Health and other services to individuals [ ] Youth activities [ ] Business, professional, employee, and fraternal [ ] Sports, athletic, recreational, and social [ ] Conservation and environmental [ ] Public opinion advocacy and legal aid [ ] Other, describe: _____________________________________________________ _____________________________________________________________________________ 7. Summarize the charitable organization's programs and activities that support the stated purposes. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 8. Describe how a citizen could verify or observe these programs and activities. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 9. Under what names (other than the name on line 1) will contributions be solicited? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 10. List the names and titles of three officers or employees receiving the greatest total amount of compensation from the charitable organization: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 11. Attach a list of names, addresses, and telephone numbers of officers of the charitable organization unless (check if applicable): [ ] State non-profit corporation registration is current. 12. The number of expected solicitation campaigns during the period covered by this registration: ________________________________________________________ 13. List the names, addresses, and telephone numbers of the paid solicitors under contract to provide fund-raising services for the charitable organization during this reporting year: (a) _________________________________________________________________________ Name Address Phone ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ (b) Is there a written contract for each service provided by the paid solicitor in 13? Yes [ ] No [ ] (c) How is the paid solicitor's compensation calculated under the contract? Describe the formula or other method of calculating compensation: ____________ ___________________________________________________________________________ 14. Federal tax exempt status: [ ] applied for on _ / _ / _ [ ] Exemption not requested. [ ] 501 (c)(3) granted [ ] Exemption denied. Federal employer ID no. ____________________________ 15. Check the form numbers of the returns filed with the Internal Revenue Service for the most recent fiscal year. [ ] None [ ] 990/990EZ [ ] Sched. A, 990 [ ] 990-PF [ ] 990-T [ ] 5227 [ ] 1041 [ ] 1041-A [ ] 1041-B [ ] 4720 [ ] Other __________________________________________ 16. (a) Did the charitable organization file a form 990 for the most recent fiscal year? Yes [ ] No [ ] (b) Did the charitable organization have an audited financial report prepared for the most recent fiscal year? Yes [ ] No [ ] (c) If you checked "yes" to either 16(a) or 16(b), you may attach the most recently completed Form 990 or audited financial report to this registration, and skip to item 18. If you checked "no" to both 16(a) and 16(b), you must compete items 16(d)(1) - (d)(10) and 17. (d) Financial report for the fiscal year ending: (Date) __________________ 1. Gross revenue from all sources: _____________ 2. (Subtract) cost of goods sold: _____________ 3. TOTAL; REVENUE: . . . . _____________ 4. Gross fund-raising expenses: _____________ 5. (Subtract) cost of goods sold: _____________ 6. Cost of solicitation: _____________ 7. Management & general expenses: _____________ 8. AMOUNT APPLIED TO CHARITABLE PURPOSE: _____________ 9. Total expenses (Add Lines 6, 7, & 8) _____________ 10. Surplus:(deficit) (subtract line 9 from line 3): 17. Did the charitable organization pay for the fund-raising services of any of the following "outside entities"? (a) [ ] No outside entity retained [ ] Contract employee [ ] Paid solicitor ( AS 45.68.900 (4)) Name and address: ___________________________________________________________ _____________________________________________________________________________ (b) Was part of the amount paid to "outside entities" included in Line 16(d)(8) of the financial report? Yes [ ] No [ ] (c) If the answer to 17(b) is "yes," provide the following information: Total amount paid to "outside entities" ___________________________________ ___________________________________________________________________________ Amount of line 16(d)(8) paid to "outside entities" ___________________________________________________________________________ I certify, under penalty of unsworn falsification in violation of AS 11.56.210 , that the information contained in this Charitable Organization Registration Form is true and correct to the best of my knowledge. ____________________________ Date ____________________________ (signature of registrant) ____________________________ (printed name/title)

History: Eff. 3/19/94, Register 129

Authority: AS 45.68.010

AS 45.68.020

AS 45.68.130

Editor's note: The address for filing charitable organization registration statements or obtaining information about those statements is the Alaska Department of Law, Fair Business Practices Section, 1031 West 4th Avenue, Suite 200, Anchorage, Alaska 99501-1994.