Form Ss-6001 - Application For Registration Of A Charitable Organization - Departament Of State, State Of Tennessee
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1
2WARNING:
False
or
misleading
statements
subject to maximum $5,000 penalty. T.C.A. §48-101-514
APPLICATION FOR REGISTRATION
Charitable Solicitations
OF A CHARITABLE ORGANIZATION
312 Eighth Avenue North
8th Floor, William R. Snodgrass Tower
Nashville, TN 37243-0308
(615) 741-2555
OFFICE USE ONLY
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 addi-
Reg. No.
Date Rec'd.
tional sheets. Indicate that an item does not apply by placing N/A by its number. A
nonrefundable registration fee must accompany this application. The amount of the
filing fee is as follows:
Initial application. $50.00 Filing Fee
Fee Pd.
Renewal of Registration. (Based on gross revenue from all sources.)
Organization's
Annual
Gross Revenue
Filing Fee
0 - $48,999.99 ..................................... $100.00
Rec. No.
$ 49,000 - $99,999.99 ..................................... $150.00
$100,000 - $249,999.99 ................................... $200.00
$250,000 - $499,999.99 ................................... $250.00
$500,000 - and above ....................................... $300.00
1. A. Name of organization. ___________________________________________________________________________
B. Federal Employer Identification Number: _____________________________________________________________
C. Address of principal office.
(Include Street, City, County, State, Zip Code) ______________________________________________
D. If organization does not maintain an office, give the name and address of the person having custody of its financial
records.
_____________________________________________________________________________________________________
E. Mailing address, if different from principal office.________________________________________________________
F . Fax Number: _______________
Telephone Number:_______________
E-Mail Address:____________________
G . Does organization have other offices in the state of Tennessee?
If the answer is "Yes", list addresses below:
(Include Street, City, State, Zip Code)
1._______________________________________________________________________________________
2.________________________________________________________________________________________
3._______________________________________________________________________________________
If you solicit contributions under any name(s) other than that shown in 1.A., indicate name(s) below
H.
:
1._______________________________________________________________________________________
2._______________________________________________________________________________________
Attach copies of document(s) authorizing your solicitation of contributions under name(s) shown above.
2. A. List the name, title, address, telephone number and date of birth for all officers, trustees and directors of organization. (List chief salaried
officer first.)
Name (Last Name, First Name, M.I.)
Title
Address (Include Street, City, State, Zip Code)
Phone
Date of Birth
1.
2.
3.
4.
B. Attach a ten-year employment history of the organization's "control" or "key" person(s). "Control" or "key" persons
are persons in control of the day-to-day operation of the organization.
3.
Describe the purpose of the organization.
4. A. Legal entity of organization.
Corporation
Partnership
Association
Other (Specify)
B. When and where was legal entity organized?
Date:
City:
State:
C. Beginning and ending dates for fiscal year of organization. ___________________________________________
5. A. If this is your organization's initial registration, please attach a copy of your charter, bylaws or other similar
governing document.
Initial copy attached
N/A
B. Attach a copy of any amendments to your organization's corporate charter, bylaws or other governing document.
6.
Has organization ever received tax exemption from Internal Revenue Service? Yes
No
A. If the answer is "Yes", the date original Internal Revenue Service tax exempt status granted. ___________________
Date (Month, Day, Year)
B. Has your tax exempt status classification(s) ever been revoked by the Internal Revenue Service? Yes
No
If "Yes", attach a copy of letter of revocation and a written summary of the basis of the revocation.
C. If you have applied for a tax exempt classification with the Internal Revenue Service, but have not received a final
determination letter:
(1) Attach copy of application.
Yes
N/A
(2) Attach copy of Internal Revenue Service letter acknowledging receipt of application.
Yes
B. Are you registering and reporting the
7. A. List all Chapters, Branches, & Affiliates of Organization which are located in Tennessee.
Financial Activities for this agency?
Name of Chapter, Branch or Affiliate
Street,City, State, Zip Code
Yes
No
1.________________________________________________________________
Yes
No
2.________________________________________________________________
Yes
No
3.________________________________________________________________
C. List name, title, & phone number of the Chief Executive Officer of each agency you checked "No" in 7.B.
Last Name
First Name
Title
Phone #
1._______________________________________________________________________________________
2._______________________________________________________________________________________
3._______________________________________________________________________________________
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