Form Ct-12 - Charitable Activities Section - 2003
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1
2Form
Charitable Activities Section
For Accounting Periods Beginning in:
CT-12
Oregon Department of Justice
2003
1515 SW 5th Avenue, Suite 410
VOICE (503) 229-5725
Portland, OR 97201-5451
TTY
(503) 378-5938
For Oregon Corporations
E-Mail: charitable.activities@doj.state.or.us
FAX
(503) 229-5120
and Certain Trusts
Web site:
Section I.
General Information
1.
Cross Through Incorrect Items and Correct Here:
(See instructions for change of name or accounting period.)
Registration #:
Organization Name:
Address:
City, State, Zip:
Phone:
Fax:
Amended
Report?
Period Beginning:
/
/
Period Ending:
/
/
2.
Did a certified public accountant audit your financial records? - If yes, attach a copy of the auditor’s report, financial statements,
Yes
No
accompanying notes and any schedules presented as supplementary information to the basic financial statements.
3.
Is the organization a party to a contract involving person-to-person, advertising, vending machine or telephone fund-raising in
Oregon?
Yes
No
If yes, write the name of the fund-raising firm(s) who conducts the campaign(s):_____________________________________
4.
Has the organization or any officer, director, or executive personnel of the organization ever been involved in a voluntary
agreement with any district attorney or attorney general or a legal action in any court regarding the organization’s solicitation,
Yes
No
administration, or management practices? If yes, attach copies of the agreement and a written explanation.
5.
During this reporting period, did the organization amend its articles of incorporation, bylaws, or trust documents, OR did the
organization receive a determination letter from the Internal Revenue Service indicating a new or amended tax-exempt status?
Yes
No
If yes, attach a copy of the amended document or letter.
Yes
No
6.
Is the organization ceasing operations and is this the final report? (If yes, see instructions.)
7.
Provide contact information for the person responsible for retaining the organization’s records.
Name
Position
Phone
Mailing Address
8.
List of Officers, Directors, Trustees and Key Employees – List each person who held one of these positions at any time during the year even if they did
not receive any compensation from the organization. Attach additional sheets if necessary. If an IRS form is attached that includes substantially the
same information, the phrase “See IRS Form” may be entered in lieu of completing this section.
(A) Name, daytime phone number
(B) Title &
(C)
(D) Contributions
(E) Expense
& mailing address
average weekly
Compensation
to benefit plans
account & other
hours devoted to
(If not paid,
& deferred
allowances
position
enter $0)
compensation
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(
)
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(
)
Name:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone:
(
)
Form Continued on Reverse Side
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