Form CRI-300R Long-Form Renewal Registration/Verification

New Jersey Ofﬁce of the Attorney General

Division of Consumer Affairs

Ofce of Consumer Protection

Charities Registration Section

124 Halsey Street, 7

Floor, P.O. Box 45021

Newark, NJ 07101

(973) 504-6215

Form CRI-300R

Long-Form Renewal Registration/Verication Statement

Pursuant to the New Jersey Charitable Registration and Investigation Act (also known as “the C.R.I. Act” (N.J.S.A. 45:17A-18 et seq.),

and prior to operating or commencing solicitation activity in the State, a charitable organization unless exempted from registration

requirements (or qualied to le a Short-Form Registration Statement, CRI-200) shall le a Long-Form Initial Registration Statement,

CRI-150-I. Charities submitting their annual long-form renewal registration must use Form CRI-300R. Please see the checklist at the

end of this form for a discussion of fees, nancial statements, documents to be attached, and other requirements for registration.

1. This statement contains the facts and nancial information for the scal year ending: _____/ _____/ ________

month day year

2. Federal ID Number (EIN) __________________ 2a. N.J. Charities Registration Number: CH- _________________________

3. Full legal name of the registering organization: ______________________________________________________________

In care of: (if necessary, otherwise leave this line blank) __________________________________________________________

4. Mailing Address: ____________________________________________________________________ £ Change of Address

Street Address City State ZIP Code

NOTE: If “ in care of,” a postal, private or rural delivery mail box number is used, the street address of the charity must be given below.

5. The principal street address of the registering organization________________________________________________________

£ Same as Mailing Address

Street Address City State ZIP Code

6. Does the organization have any ofces in New Jersey in addition to the one listed above? £ Yes £ No

If “Yes,” attach a list giving the street address and telephone number of each ofce in New Jersey.

6a. If the street address listed above is not where the organization’s ofcial records are kept, or if the organization does not maintain an

ofce in New Jersey, indicate the name, full address, phone and fax number of the person having custody of the of the organization’s

records, and to whom correspondence should be addressed.

_______________________________________________________________________________________________________

Contact person Street address City State ZIP Code

________________________________ ________________________________

Telephone number (include area code) Fax number (include area code)

7. Organization’s contact information:

________________________________ ________________________________

Telephone number (include area code) Fax number (include area code)

________________________________ ________________________________

E-mail address Web site

8. Type of organization (check one):

£ Nonprot corporation £ Foundation £ Individual £ Association £ Society

£ Partnership £ Trust £ Other (Specify) ____________________________________

All questions must be answered.

Form CRI-300R Page 1 of 7

(Revised April 2008)

9. Where and when was the organization legally established? Date: ____________________ State: _____________________

As required by the C.R.I. Act (N.J.S.A. 45:17A-24c(1)), attach to this registration a copy of the organization’s bylaws and

instrument of organization (that is, the organization’s charter, articles of incorporation or organization, agreement of association,

instrument of trust, or constitution) only if the document has been issued or amended during the scal year being reported.

10. Does the organization solicit funds under any name or names other than as indicated on line 3 of this form? Yes No

If “Yes,” indicate all of the other names used: _________________________________________________________________

11. Does the organization intend to solicit contributions from the general public? Yes No

12. Is the organization authorized by any other state or jurisdiction to solicit contributions? Yes No

If “Yes,” please provide a list of those states or jurisdictions, below or on a separate sheet of paper.

_______________________________________________________________________________________________________

13. Does the organization have afliates which share the contributions or other revenue it raised in New Jersey? Yes No

If “Yes,” provide a separate listing of those afliates indicating the name, street address and telephone number for each one.

14. What is the charitable purpose or purposes for which the organization was formed? If necessary, attach a separate statement to this

registration.

_______________________________________________________________________________________________________

14a. What are the specic programs and charitable purposes for which contributions are used? For each program, state whether it

already exists or is planned. Only major program categories need be listed. If necessary, attach a separate statement to this

registration.

_______________________________________________________________________________________________________

15. Does the organization use an independent paid fund-raiser or fund-raising counsel? Yes No

If “Yes,” please attach to this registration a list of paid fund-raiser(s) or fund-raising counsel(s), including their full address, telephone

number, fax number, registration number in New Jersey, and a contact person’s name.

15a.

Does the independent paid fund-raiser or fund-raising counsel have custody, control or access to the organization’s funds?

Yes No

If “Yes,” please describe the situation.

_______________________________________________________________________________________________________

16. Has the organization permitted a charitable sales promotion to be conducted on its behalf by a commercial co-venturer during the

scal year-end being reported? Yes No

If “Yes,” please explain: ___________________________________________________________________________________

_______________________________________________________________________________________________________

17. Has the Internal Revenue Service (I.R.S.) determined that the organization is tax exempt under code 501(c)(3)? Yes No

a. If “No,” has an application been led which is still pending? If so, please attach a copy of the

I.R.S. 1023 form led. Yes No

b. Has a tax exemption been granted under another I.R.S. code? Yes No

If “Yes,” advise which one: ____________________________

c. Has an I.R.S. tax exemption been refused, changed or revoked? Yes No

If an exemption has been refused, changed or revoked, attach to this registration a copy of the I.R.S. determination letter of

notication and provide a detailed explanation of the circumstances on a separate sheet of paper.

8. Type of Organization

(check one)

Nonprot corporation

Foundation

Individual

Association

Society

Partnership

Trust

Other (Specify)

8. Type of Organization (check one)

Nonprot corporation

Foundation

Individual

Association

Society

Partnership

Trust

Other (Specify)

Form CRI-300R Page 2 of 7

18. Has the organization ever had its authority to conduct charitable activities denied, suspended, or revoked in any jurisdiction or has the

organization ever entered into any voluntary agreement of discontinuance with any governmental entity? Yes No

If “Yes,” attach to this registration a copy of the denial, suspension, revocation or voluntary agreement of discontinuance. If the

document does not explain the reasons for the denial, suspension or revocation, attach to this registration an explanation on a

separate sheet of paper.

19. Has the organization voluntarily entered into an assurance of voluntary compliance or similar order or agreement (including, but

not limited to, a settlement of an administrative investigation or proceeding, with or without an admission of liability) with any

jurisdiction, state or federal agency or ofcer? Yes No

If “Yes,” please attach to this registration the relevant document.

20. Has the organization or any of its present ofcers, directors, executive personnel or trustees ever been found to have engaged in

unlawful practices in the solicitation of contributions or administration of charitable assets or been enjoined from soliciting

contributions, or are such proceedings pending in this or any other jurisdiction? Yes No

If “Yes,” attach to this registration photocopies of any and all written documentation (such as a court order, administrative order,

judgment, formal notice, written assurance or other document) which show the nal disposition of the matter.

21. Has the organization or any of its present ofcers, directors, trustees or principal salaried executive staff employees ever been

convicted of any criminal offense committed in connection with the performance of activities regulated under this act or any

criminal or civil offense involving untruthfulness or dishonesty or any criminal offense relating adversely to the registrant’s

tness to perform activities regulated by this Act? A plea of guilty, non vult, nolo contendere or any similar disposition

of alleged criminal activity shall be deemed a conviction. Yes No

22. Has the organization or any of its ofcers, directors, trustees or principal salaried executive staff employees been adjudged liable

in any administrative or civil action involving theft, fraud, or deceptive business practices? For purposes of this question a judgment

of liability in an administrative or civil action shall include, but is not limited to, any nding or admission that the individual engaged

in an unlawful practice in relation to the solicitation of contributions or the administration of charitable assets. Yes No

If “Yes,” identify the individual(s) below and attach to this registration a copy of any order, judgment or other documents indicating

the nal disposition of the matter.

_______________________________________________________________________________________________________

23. Provide the following information for each ofcer, director, trustee and the ve most-highly compensated executive staff

employees:

Name Business address Telephone number Title Salary

(include area code)

_______________________________________________________________________________________________________

______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Form CRI-300R Page 3 of 7

CRI-300R Long-Form Registration Renewal Financial Statement

Note: If the nancial value of a line item = 0, place a zero in the space provided.

Please report all gures as GROSS, not NET.

Full

legal name and street address of the organization

Full legal name:__________________________________________________________________________________________

Fiscal year-end being reported: _____/_____/_____ Federal ID Number (EIN) __________________

month day year

Mailing address:

_______________________________________________________________________________________________________

Mailing Address P.O. Box Number or Suite City State ZIP code

Street address of the registering organization: __________________________________________________________________

Street Address City State ZIP Code

New Jersey Charities Registration number: CH _______________ -00 Telephone number: _________________________

(include area code)

Attach to this registration the most recent Internal Revenue Service Form 990 and Schedule A (990), if the organization has led those

forms. Attach a copy if the organization’s annual nancial report included an audited nancial statement, or if the organization

received gross revenue in excess of $500,000. Note: If the organization received gross revenue of less than $500,000,

the nancial reports must be certied by the organization’s president or other authorized ofcer of the organization’s board.

£ In lieu of completing the CRI-300R Financial Statement pages, attached please nd a copy of the I.R.S. 990 ling for the scal year-end

indicated above.

A. Receipts

Line A1a. Direct Public Support received from the following sources:

(1) Direct mail ……………………………………….... __________________

(2) Telephone solicitation…………………………….... __________________

(3) Commercial co-venture…………………………..... __________________

(4) Gross receipts from fund-raising events…………… __________________

(5) Canisters, counter cards, door to door etc…………. __________________

(6) Corporations and other businesses…………………. __________________

(7) Foundations and trusts……………………………... __________________

(8) Donated land, buildings, property, equipment and

materials……………………………………………. __________________

(9) Legacies and bequests……………………………… __________________

(10) Membership dues solely resulting from

solicitations………………………………................ __________________

(11) Other support (specify)…………………………...... __________________

Line A1b. Total Direct Public Support (add lines A1a(1) through A1a(11) ...… __________________

Line A1c. Indirect Public Support received from the following sources:

(1) Federated fund-raising organization……………….. __________________

(2) From an afliated organization…………………….. __________________

(3) From another fund-raising organization………….... __________________

Line A1d. Total Indirect Public Support (add lines Alc(1) thru A1c(3))…........ __________________

Line A1e. Total Gross Contributions (add lines A1b and A1d) ………...…… __________________

Form CRI-300R Page 4 of 7

Line A2. Government grants including purchase of service contracts (specify agency)

a. …………………………………………………................ __________________

b. …………………………………………………................ __________________

c. …………………………………………………................ __________________

d. …………………………………………………................ __________________

Line A2e. Total Government Grants (add lines 2a thru 2d)..…………………..... __________________

Line A3. Other Support

a. Bona de membership ………………………................... __________________

b. Program service revenue…………………….................... __________________

c. Professional services rendered by volunteers………......... __________________

d. Miscellaneous income (specify)………………................. __________________

Line A3e. Total Other Support (add the total of lines A3a thru A3d)…..…........ __________________

Line A4. Total Gross Revenue (add lines A1e, A2e and A3e) …………......... __________________

B. Expenses

Line B1. Program expenses…………………………………................... __________________

Line B2. Management and general expenses……………….................... __________________

Line B3. Fund-raising expenses…………………………….................... __________________

Line B4. Payments to state/national afliates (if applicable).................... __________________

Line B5. Total Expenses (add the totals of line B1 thru B4)…..……...... __________________

C. Excess or Decit

For the scal year-end (subtract line B5 from line A4)…………….................. __________________

D. Fund Balance

Line D1. Net assets or fund balances at beginning of year…………….... __________________

Line D2.

Other changes in net assets or fund balances (attach explanation)

….. __________________

Line D3.

Net assets or fund balances at end of year (Combine line C, D1 and D2)

... __________________

Please Note: The amount of Gross Contributions ( line A1e on this form) determines the registration fee which must be paid and the

form which should be used. July 2006 revisions to the Charities Registration Act now require all charities to pay a registration fee,

including charities whose Gross Contributions are less than $10,000. Further information for charity registrants may be found on our

Web site: http://www.njconsumeraffairs.gov/ocp/charities.htm.

Form CRI-300R Page 5 of 7

Long-Form Renewal Registration Statement

Form CRI-300RC

Condential Information

Organization’s Name: _________________________________________________________________________________

N.J. Charities Registration Number: CH -__________ -00 Federal ID Number (EIN) ______________

Fiscal Year-End being reported: ____ / _____ / ____

month day year

24. Are any of the organization’s ofcers, directors, trustees or the ve most-highly compensated employees related by blood,

marriage or adoption to:

a. each other? £ Yes £ No

b. any ofcers, agents or employees of any fund-raising counsel or independent paid fund-raiser under contract to the

organization? £ Yes £ No

c. any chief executive, employee, any other employee of the organization with a direct nancial interest in the transaction,

or any partner, proprietor, director, ofcer, trustee, or to any shareholder of the organization with more than two (2)

percent interest in any supplier or vendor providing goods or services to the organization? £ Yes £ No

d. If you answered “Yes,” to questions 24a, b, or c, please provide a statement explaining these relationships.

25. Do any of the organization’s ofcers, directors, trustees or the ve most-highly compensated employees have a nancial

interest in any activities engaged in by a fund-raising counsel or independent paid fund-raiser under contract to the organization,

or any supplier or vendor providing goods or services to the organization? £ Yes £ No

If “Yes,” please detail these relationships below or on a separate sheet of paper, and provide the name, business address and

telephone number of all interested parties.

We understand that this registration is being issued at the discretion of the Division of Consumer Affairs and agree that employees

of the Division may inspect the records in the possession of this organization in order to ascertain compliance with the statute and all

pertinent regulations. We also understand that we may be required to provide additional information if requested.

We hereby certify that the above information and the attached nancial schedule(s) and statement(s) are true. We are aware that if any

of the above statements are willfully false, we are subject to punishment.

Signature____________________________ Name______________________________ Title ______________ Date ____________

This form must be signed by two (2) authorized ofcers of the organization, including the chief nancial ofcer.

Note: Form CRI-300RC must be led with Form CRI-300R.

Form CRI-300R Page 6 of 7

Renewal registrants who are required to le the

Long-Form Renewal Registration/Verication Statement CRI-300R/RC

must submit the following:

(1)

A fully completed Long-Form Renewal Statement CRI-300R along with the CRI-300R Financial Statement, the CRI-300RC

Condential Information Statement (with signatures), and all lists, statements and attachments as may be required by

answers to the form’s questions.

(2) All charity registrants in New Jersey must pay a registration fee based on gross contributions. Please visit our Web site at

www.njconsumeraffairs.gov for a complete schedule of registration fees due. A check or money order for the registration

fee due, made payable to the New Jersey Division of Consumer Affairs, must accompany the registration form. Cash or

credit card payments cannot be accepted. Initial registrations must be submitted prior to soliciting in the State of New

Jersey. Registrations must be renewed annually, and are due within six months of the scal year-end. Extensions of time to

le cannot be granted on initial (rst-time) registrations.

(3) Charity registrants with total gross revenue in excess of $500,000 annually are required to submit a certied audit (including

any management letters) which has been prepared by a certied public accountant.

(4) Please write the organization’s charities registration number on all checks, forms, and copies of documents submitted.

(5) If the charity was required by the Internal Revenue Service to le an IRS-990 form for the organization’s scal year-end

being reported, a copy, including Schedule A, must be submitted with the registration form.

(6) Photocopies of any orders, judgments, agreements or other documents which show the nal disposition of any civil or

criminal actions brought against the organization or its board members, must be marked with the related question number

and the charities registration number.

(7) Only initial registrants must submit photocopies of the organization’s bylaws, the certicate of incorporation and the I.R.S.

determination letter. However, copies of these documents must be resubmitted each time they are amended.

(8) Mail the completed registration, enclosures and any attachments to the:

New Jersey Division of Consumer Affairs

Charities Registration & Investigation Section

P.O. Box 45021

Newark, NJ 07101

Should you have questions regarding charities registration in New Jersey, please visit our Web site at

http://www.njconsumeraffairs.gov/ocp/charities.htm where registration information, instructions, forms and a fee schedule

may be viewed and/or downloaded. After reading through all of the information on our Web site, if you have further questions,

please contact the Charities Registration Section at our hotline number (973)-504-6215 during regular business hours.

Form CRI-300R Page 7 of 7