Form Cri 300R – Fill Out and Use This PDF

New Jersey Office of the Attorney General

DIVISION OF CONSUMER AFFAIRS

Ofice of Consumer Protection

Charities Registration Section

124 Halsey Street, 7th Floor, P.O. Box 45021

Newark, NJ 07101

(973) 504-6215

FORM CRI-300R

Long-Form Renewal Registration/Veriication Statement

(Revised April 2008)

All questions must be answered.

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 qualiied to ile a Short-Form Registration Statement, CRI-200) shall ile 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, inancial statements, documents to be attached, and other requirements for registration.

1.This statement contains the facts and inancial information for the iscal 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

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________________________________________________________

records, and to whom correspondence should be addressed.

_______________________________________________________________________________________________________

8.Type of organization (check one):

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

15a. Does the independent paid fund-raiser or fund-raising counsel have custody, control or access to the organization’s funds?

If an exemption has been refused, changed or revoked, attach to this registration a copy of the I.R.S. determination letter of notiication and provide a detailed explanation of the circumstances on a separate sheet of paper.

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

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

20.Has the organization or any of its present oficers, 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

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 inal disposition of the matter.

21. Has the organization or any of its present oficers, 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

22.Has the organization or any of its oficers, 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 inding or admission that the individual engaged

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

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

23.Provide the following information for each oficer, director, trustee and the ive most-highly compensated executive staff employees:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

CRI-300R Long-Form Registration Renewal Financial Statement

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

Please report all igures 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 AddressP.O. Box Number or SuiteCityStateZIP code

Street address of the registering organization: __________________________________________________________________

Street AddressCityStateZIP Code

Attach to this registration the most recent Internal Revenue Service Form 990 and ScheduleA(990), if the organization has iled those forms. Attach a copy if the organization’s annual inancial report included an audited inancial 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 inancial reports must be certiied by the organization’s president or other authorized oficer of the organization’s board.

£In lieu of completing the CRI-300R Financial Statement pages, attached please ind a copy of the I.R.S. 990 iling for the iscal year-end indicated above.

A. Receipts

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

Long-Form Renewal Registration Statement

FORM CRI-300RC

Conidential Information

Organization’s Name: _________________________________________________________________________________

24.Are any of the organization’s oficers, directors, trustees or the ive most-highly compensated employees related by blood, marriage or adoption to:

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

c.any chief executive, employee, any other employee of the organization with a direct inancial interest in the transaction, or any partner, proprietor, director, oficer, trustee, or to any shareholder of the organization with more than two (2)

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 oficers, directors, trustees or the ive most-highly compensated employees have a inancial 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 inancial 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 ____________

Signature____________________________ Name______________________________ Title ______________ Date ____________

This form must be signed by two (2) authorized oficers of the organization, including the chief inancial oficer.

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

Renewal registrants who are required to ile the

Long-Form Renewal Registration/Veriication Statement CRI-300R/RC

must submit the following:

(1)A fully completed Long-Form Renewal Statement CRI-300R along withtheCRI-300RFinancial Statement, theCRI-300RC Conidential 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 iscal year-end. Extensions of time to ile cannot be granted on initial (irst-time) registrations.

(3)Charity registrants with total gross revenue in excess of $500,000 annually are required to submit a certiied audit (including any management letters) which has been prepared by a certiied 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 ile an IRS-990 form for the organization’s iscal 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 inal 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 certiicate 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.