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Form CHAR410		Registration Statement for Charitable Organizations
Form CHAR410		New York State Department of Law (Office of the Attorney General)					Open to Public
			Charities Bureau - Registration Section				Open to Public
	For new registrants only		28 Liberty Street				Inspection
	(Amending use CHAR410-A,		New York, NY 10005
Re-registering use CHAR410-R)			www.charitiesnys.com/


Part A - Identification of Registrant

1.	Full name of organization (exactly as it appears in your organizing document)				5.	Fed. employer ID no. (EIN)
						__ __ - __ __ __ __ __ __ __

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 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

	Signature		Printed Name	Title	Date
2. Chief Financial Officer or Treasurer
2. Chief Financial Officer or Treasurer
	Signature		Printed Name	Title	Date


Part C - Fee Submitted

If registering to solicit contributions, fee is $25.		Check -9	if you are submitting $25 fee to	Submit check or money order,
If not registering to solicit contributions, no fee is owed.			register to solicit contributions.	payable to “NYS Department of Law.”
			register to solicit contributions.

Part D - Attachments - All Documents Required

Attach all of the following documents to this 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 Schedule E.

Page 1 of 3

Form CHAR410 (2018)

Part F - Organization Structure

1. Incorporation / formation

a. Type of organization:

b. Type of corporation if New York not-for-profit corporation

Corporation

A G B G C G

D G

Limited liability company (LLC)

. . . . . . . . . . . . . . . . . . . . . . . . . .Partnership

Date incorporated if a corporation or formed if other than a corporation

Sole proprietorship

Trust

__ __ / __ __ / __ __ __ __

. . . . . . . . . . . . . . . . . . . . . . . . . .Unincorporated association . .

State in which incorporated or formed

Other *

* If Other, describe:

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

Mailing address (number and street, room/suite,

Name

Relationship

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

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

Page 2 of 3

Form CHAR410 (2018)

Part G - Organization Activities

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)

			Type of FRP			Mailing address (number and street, room/suite,
	Name		(see instructions for definitions)							city or town, state or country and zip+4)																																				Dates of contract

			PFR	G																																												Start date:	_ _ / _ _ / _	_ _ _
			PFR	G
			FRC	G																																												End date:	_ _ / _ _ / _ _ _ _
			FRC	G
			CCV	G
			CCV	G

			PFR	G																																												Start date:	_ _ / _ _ / _	_ _ _
			PFR	G
			FRC	G																																												End date:	_ _ / _ _ / _ _ _ _
			FRC	G
			CCV	G
			CCV	G

			PFR	G																																												Start date:	_ _ / _ _ / _	_ _ _
			PFR	G
			FRC	G																																												End date:	_ _ / _ _ / _ _ _ _
			FRC	G
			CCV	G
			CCV	G


Part H - Federal Tax Exempt Status

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)( ___ )

Page 3 of 3

Form CHAR410 (2018)

Question	Answer
Form Name	Form Char410
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	410 form download, char 410, char410 online, 410 form

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