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Wisconsin Department of Regulation & Licensing

Mail To:

P.O. Box 8935

1400 E. Washington Avenue

Madison, WI 53708-8935

Madison, WI 53703

FAX #:

(608) 261-7083

E-Mail: web@drl.state.wi.us

Phone #:

(608) 266-2112

Website:

DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING

AFFIDAVIT IN LIEU OF ANNUAL FINANCIAL REPORT

Sections 440.42(3) and 440.455(4), Stats.

NOTE: Every charitable organization which files one or both of the affidavits on the

next two pages must provide ALL of the information on the front

side of this form and the top of the next page.

TYPE OR PRINT IN INK

NAME OF ORGANIZATION

WISCONSIN REGISTRATION NUMBER

ADDRESS

FEDERAL EMPLOYER I.D. NUMBER

(NUMBER AND STREET) OR P.O. BOX

CITY OR TOWN, STATE, ZIP CODE

ORGANIZATION’S DAYTIME PHONE

NUMBER (

) _____ - _____________

INDICATE ORGANIZATION TYPE

ACCOUNTING METHOD

___Cash

___Civic & Social Action

___Health Services

___Culture

___Other (Specify)

___Accrual

___Education & Research

___Human Services

___Other

ACCOUNTING PERIOD DATE:

Beginning Date ___________________

Ending Date ____________________

Attach a list of all officers, directors, trustees and the principal salaried employees. Include

their name, address, title, and the date their term ends. Compensation must be clearly stated.

YES NO

For solicitations in Wisconsin, did your organization use a professional fund-raiser or

fund-raising counsel or did your organization pay a person to solicit contributions, other than a

salaried officer or employee of your organization, during the above-referenced accounting

period? If YES, indicate the name and address in this space.

Has any of the information submitted to the Department in the past changed, such as, the name

of the organization, the address of the principal office or any branch office located in

Wisconsin, the accounting period, the names of the persons within the organization who have

final authority for custody or final distribution of contributions, or the articles, by-laws or

statement of purpose? If YES, and not already submitted within 30 days after the change, as

required by law, explain changes on separate sheet. If a corporation, and the name has

changed, you must attach a copy of the name change amendment.

Is your organization authorized by any other governmental authority to solicit contributions? If

YES, provide the name and address of the governmental authority.

#1943 (Rev. 12/05)

Ch. 440, Stats.

Page 1 of 4

Committed to Equal Opportunity in Employment and Licensing

Form 1943 - Affidavit In Lieu Of Annual Financial Report - Wisconsin Department Of Regulation & Licensing

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