Char410 A Form – Fill Out and Use This PDF

Part A - Identification of Registrant

1.	Full name of organization (exactly as it appears in your organizing document)		5.	Identification numbers
				a. Fed. employer ID no. (EIN)
				__ __ - __ __ __ __ __ __ __
				b. NY State registration no.
				__ __ - __ __ - __ __
2.	c/o Name (if applicable)		6.	Organization’s website
3.	Mailing address (Number and street)	Room/suite	7.	Primary contact
	City or town, state or country and ZIP+4			Title
4.	Principal NYS address (Number and street)	Room/suite		Phone	Fax
	City or town, state or country and ZIP+4			Email

Part B - Certification - Two Signatures Required

We certify under penalties for perjury that we reviewed this Amended Registration Statement, including all schedules and attachments, and to the best of our knowledge and belief, they are true, correct and complete in accordance with the laws of the State of New York applicable to this statement.

1. President or Authorized Officer/Trustee

SignaturePrinted NameTitleDate

2. Chief Financial Officer or Treasurer

SignaturePrinted NameTitleDate

Part C - Fee Submitted

	• Current EPTL registrants amending registration to
	solicit contributions, fee is $25.
	• Current EPTL registrants not soliciting	Check -G	if you are submitting $25 fee.	Submit check or money order,
	contributions, no fee is owed.			payable to “NYS Department of Law.”
	• Current Article 7-A or dual registrants, no fee is
	owed.

Part D - Attachments - All Documents Required

Attach to this Amended Registration Statement all amendments to the following documents previously filed with a prior Registration Statement, Amended Registration or Re-Registration Statement, even if you are claiming an exemption from registration:

• Certificate of incorporation, trust agreement or other organizing document, and any amendments; and

• Bylaws or other organizational rules, and any amendments; and

• IRS Form 1023 or 1024 Application for Recognition of Exemption (if applicable); and

• IRS tax exemption determination letter (if applicable)

Part E - Request for Registration Exemption

Is the organization requesting exemption from registration under either or both Article 7-A or the EPTL? . . . . . . . . . . . . . . . . . . . . . . . . . G Yes* G No

* If “Yes”, complete and attach Schedule E.

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Form CHAR410-A (2018)

Part F - Organization Structure - Provide Only Information Changed Since Last Registration, Amended Registration, Re-Registration or Annual Filing

1. Incorporation / formation

	a. Type of organization:		b. Type of corporation if New York not-for-profit corporation
	Corporation	G		A G B G C G D G
	Limited liability company (LLC)	G
	Partnership	G c.		Date incorporated if a corporation or formed if other than a corporation
	Sole proprietorship	G
	Trust	G		__ __ / __ __ / __ __ __ __
	. . . . . . . . . . . . . . . . . . . . . . . . . .Unincorporated association . .	G	d.	State in which incorporated or formed
	* Other	G

*If Other, describe:

2.List all chapters, branches and affiliates of your organization (attach additional sheets if necessary)

3.List all officers, directors, trustees and key employees

Mailing address (number and street, room/suite,

End of term

Name

Title

city or town, state or country and zip+4)

(if applicable)

_ _ / _ _ / _ _ _ _

_ _ / _ _ / _ _ _ _

_ _ / _ _ / _ _ _ _

_ _ / _ _ / _ _ _ _

_ _ / _ _ / _ _ _ _

_ _ / _ _ / _ _ _ _

_ _ / _ _ / _ _ _ _

_ _ / _ _ / _ _ _ _

4.Other Names and Registration Numbers

a.List all other names used by your organization, including any prior names

b.List all prior New York State charities registration numbers for the organization, including those from the New York State Attorney General’s Charities Bureau or the New York State Department of State’s Office of Charities Registration

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Form CHAR410-A (2018)

Part G - Organization Activities - Provide Only Information Changed Since Last Registration, Amended Registration, Re-Registration or Annual Filing Re-Registration

1. Month the annual accounting period ends (01-12)	2. NTEE code

3.Date organization began doing each of following in New York State:

a.	conducting activity	__ __ / __ __ / __ __ __ __
b.	maintaining assets	__ __ / __ __ / __ __ __ __
c.	soliciting contributions (including from residents, foundations, corporations, government agencies, etc.)	__ __ / __ __ / __ __ __ __

4.Describe the purposes of your organization

5.Has your organization or any of your officers, directors, trustees or key employees been:

a. enjoined or otherwise prohibited by a government agency or court from soliciting contributions? . . . . . . . . . . . . . . . . . . . . . . . . . G Yes* G No

* If “Yes”, describe:

b. found to have engaged in unlawful practices in connection with the solicitation or administration of charitable assets? . . . . . . . . G Yes* G No

* If “Yes”, describe:

6. Has your organization’s registration or license been suspended by any government agency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G Yes* G No

* If “Yes”, describe:

7.Does your organization solicit or intend to solicit contributions (including from residents, foundations, corporations, government

agencies, etc.) in New York State? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G Yes* G No

* If “Yes”, describe the purposes for which contributions are or will be solicited:

8.List all fund raising professionals (FRP) that your organization has engaged for fund raising activity in NY State (attach additional sheets if necessary)

Part H - Federal Tax Exempt Status - Provide Only Information Changed Since Last Registration, Amended Registration, Re-Registration or Annual Filing

1.If applicable, list the date your organization:

a. applied for tax exempt status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __

b. was granted tax exempt status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __

c. was denied tax exempt status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __

d. had its tax exempt status revoked . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . __ __ / __ __ / __ __ __ __

2. Provide Internal Revenue Code provision: 501(c)( ___ )

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Form CHAR410-A (2018)