Solicitation Contributions – Fill Out and Use

FLORIDA DEPARTMENT OF AGRICULTURE AND

CONSUMER SERVICES

NICOLE "NIKKI" FRIED

COMMISSIONER

SOLICITATION OF CONTRIBUTIONS

REGISTRATION APPLICATION

Chapter 496, Florida Statutes

Rule 5J-7.004, Florida Administrative Code

Florida Department of Agriculture and Consumer Services

Solicitation of Contributions Registration Application

Table of Contents

Filing Instructions	Pages II – VII
Registration Application	Pages 1 – 7
Financial Statement	Page 8
Statement of Functional Expenses	Pages 9 - 10
Supplemental Consolidated Financial Statement	Page 11

FDACS-10100 Rev. 01/15 Page I of VII

INSTRUCTIONS AND CHECKLIST FOR COMPLETING THE REGISTRATION APPLICATION

STOP! Charitable organizations and sponsors that meet all the following requirements should submit FDACS-10110 Small Charitable Organizations/Sponsors Application, Rev. 01/15 in lieu of this registration application and will not be charged a fee.

[s. 496.406(1)(d), F.S.]

∙The charitable organization or sponsor has less than $25,000 in TOTAL REVENUE (including contributions).

∙The fundraising activities of the charitable organization or sponsor are carried on by volunteers, members, or officers who are not compensated and no part of the assets or income of the organization or sponsor inures to the benefit of or is paid to any officer or member of the charitable organization or sponsor.

∙The charitable organization or sponsor does not utilize a professional fundraising consultant, professional solicitor, or commercial co-venturer.

The small application can be found online at www.FreshFromFlorida.com.

NOTE: If a charitable organization or sponsor that has less than $25,000 in total revenue during a fiscal year actually acquires total revenue equal to or in excess of $25,000 or if any of the above criteria change, then the charitable organization or sponsor must register with the department as required by s. 496.405, F.S. within 30 days after the date the revenue reaches $25,000 and submit FDACS-10100 Solicitation of Contributions Application, Rev. 01/15, as incorporated in Rule 5J-7.004(2), F.A.C.

REGISTRATION AND RENEWALS

All charitable organizations and sponsors must register with the Florida Department of Agriculture and Consumer Services (FDACS) prior to engaging in solicitation activities in or from Florida, and renew annually thereafter on a form provided by the department. The department will annually provide a renewal statement to each registrant by mail at least forty-five (45) days before the renewal date. The expiration date for charitable organizations and sponsors is one (1) year from the initial date of compliance with registration requirements.

If you have any questions or need assistance in completing this application, please contact the department by calling 800- HELP-FLA (435-7352) or (850) 410-3800.

When filing an application, be certain that the application is completely filled out, that all questions are answered truthfully and that all the information requested is provided. Please type or print in ink. Additional pages may be attached if additional space is needed using the same format. Please ensure that all attachments reflect the organization’s name or registration number and the number of the corresponding question.

Item #1:

Provide the legal name of the organization exactly as it appears in its articles of incorporation or organizational document. If using a fictitious name (DBA), provide that name, also. If the organization solicits under any other names, provide those names in the spaces listed. Attach additional sheets as necessary using the same format. Note: Corporate, LLC, and Fictitious

Names are verified with the Florida Department of State, Division of Corporations and must match the name exactly as filed.

Item #2

Provide a street or physical address for the organization. Include the suite, room, or other unit number. The use of a mail drop is not acceptable. If the mailing address (i.e. a generally used post office box) is different from the organization’s street address, provide that address as well. Note: In order for correspondence to be sent directly to an attorney or other third party, you must insert the attorney’s or third party’s address as the mailing address for the organization.

Item #3

You must provide a primary telephone number, including the area code, for the organization. If the organization does not maintain a specific location, provide the telephone number of a person who will represent the organization. Also, provide the email address and website if used to provide information to or communicate with the public.

Item #4

Check the applicable box for the type of registration you are filing.

Item #5

Select the type of organization (or legal form of business) and state when and where the organization was legally established.

FDACS-10100 Rev. 01/15 Page II of VII

Item #6

Provide the organization’s federal employer identification number. Note: Taxpayers can obtain an EIN immediately by calling the IRS Business and Specialty Tax Line (1-800-829-4933).

Item #7

List the representatives as directed with complete street addresses and telephone numbers for each. (The street address may be the address of the charitable organization or sponsor.) Charitable organizations and sponsors must indicate whether or not each representative receives compensation. All documents and attachments submitted with this application are subject to public records review pursuant to Chapter 119, Florida Statutes. However, exemptions apply to certain employees. If you qualify under these exemptions, you can request that certain information be redacted from the public records available through the department. Exemptions may apply to:

∙Current or former law enforcement officers and their families

∙Current or former judges and their families

∙Current or former prosecutors and their families

∙Current or former firefighters and their families

∙Current or former human resources managers and their families

∙Current or former code enforcement officers and their families

This is not a comprehensive list. For a complete list, see s. 119.071(4), F.S. If you qualify for one of the public records exemptions and wish to have your information exempted from public review, please do not list your residence address and phone number.

Item #8a

Provide the name, address, and telephone number of any other offices, chapters, branches, or affiliates in this state for which you are filing. If you have branches and are not filing as a parent organization, each branch must register separately.

[s. 496.405(5), F.S.]

Item #8b

If your organization is not located in Florida AND you do not maintain an office in this state, provide the name, address, email, and telephone number of the person with custody of the financial records.

Item #9

Charitable organizations and sponsors must designate a person(s) who will (or would) be responsible for any solicitation or fundraising activities. (The street address may be the address of the charitable organization or sponsor.)

Item #10

You must disclose the person(s) who exercises control of funds. (i.e. the person(s) who collects the money, makes deposits, writes checks, or has custody and responsibility for the final distribution of the contributions, etc.) (The street address may be the address of the charitable organization or sponsor.)

Item #11

Indicate the month and day your accounting or bookkeeping period ends each year (fiscal year end date).

Item #12

Answer by checking appropriate box. If you have applied for but have not yet received your tax exemption determination letter, please check “pending.” In order for this office to report to consumers that your organization is tax exempt, we must have a copy of the letter from the Internal Revenue Service, which exempts your organization from paying income tax to the federal government. This letter must be on the letterhead of the Internal Revenue Service and can be for a group exemption. We cannot accept a letter from the headquarters or main office of your organization. The tax exemption determination letter is not to be confused with a Certificate of Exemption issued by the Florida Department of Revenue, which exempts your organization from paying state sales tax. Nor is it to be confused with the letter or application regarding your employer identification number also issued by the Internal Revenue Service. If you cannot locate a copy of your tax exemption letter, you must contact the Internal Revenue Service and request an additional copy.

Item #13

Briefly explain the purpose for which your organization was created. It is best to summarize this information in your own words.

Item #14

Briefly explain the purpose for which contributions will be used.

Item #15

Briefly and concisely list the main activities in which your organization participates in order to accomplish the purpose stated in the previous question.

FDACS-10100 Rev. 01/15 Page III of VII

Item #16 Answer as directed by checking appropriate box and attach contract, if applicable. We must have a current contract on file for each solicitor you employ. Include the solicitor’s Florida registration number and fill in the effective and termination dates on the blanks indicated. Note: A charitable organization or sponsor must not enter into any contractual agreement with or employ a solicitor that will perform services in Florida unless the solicitor is registered with this department. [s. 496.411(5), F.S.]

Item #17 Answer as directed by checking appropriate box and attach contract, if applicable. We must have a current contract on file for each professional fundraising consultant you employ. Include the fundraising consultant’s Florida registration number and fill in the effective and termination dates on the blanks indicated. Note: A charitable organization or sponsor must not enter into any contractual agreement with or employ a professional fundraising consultant that will perform services in Florida unless the consultant is registered with this department. [s. 496.411(5), F.S.]

Item #18

Answer by checking appropriate box and attach contract, if applicable. We must have a current contract on file for each commercial co-venturer you have an agreement with.

Item #19

Answer as directed by checking the appropriate box.

Item #20

Answer as directed by checking appropriate box and provide documentation, if applicable. Note: This includes, but is not

limited to, any assurance of voluntary compliance or settlement agreement entered into with any regulatory agency, State Attorney General’s Office, federal agency or law enforcement agency, including this department.

Item #21

Answer by checking appropriate box and provide supplementary information, if applicable. Note: All felonies must be

disclosed regardless of the nature of the crime.

Item #22

Answer by checking appropriate box and provide supplementary information, if applicable.

Item #23

Answer as directed by checking appropriate box and provide supplementary information, if applicable.

Item #24

Answer as directed by checking appropriate box and provide explanation, if applicable.

Item #25

The board of directors, or an authorized committee thereof, of a charitable organization or sponsor required to register with the department shall adopt a policy regarding conflict of interest transactions. The term “conflict of interest transaction” means a transaction between a charitable organization or sponsor and another party in which a director, officer, or trustee of the charitable organization or sponsor has a direct or indirect financial interest. A copy of the annual certification of the policy required by s. 496.4055, F.S. shall be submitted with the registration. A link to the IRS Sample Conflict of Interest Policy can be found at www.FreshFromFlorida.com.

Item #26

Indicate by checking the appropriate box which type of financial statement you are filing. Organizations must submit one of the following:

Budget - Only newly established organizations with no financial history may submit a budget for the current year. The enclosed financial statement may be used to prepare a budget.

IRS Form 990 with all attached schedules or IRS Form 990-EZ and schedule O - We cannot accept the 990-PF, 990-N, E- Postcard or 990-T or any other type of tax return. IRS Forms and schedules submitted by a charitable organization or sponsor that receives $500,000 or more in annual contributions must be prepared by a certified public accountant or another professional who prepares such forms or schedules in the ordinary course of his or her business. A charitable organization or sponsor may redact information that is not subject to public inspection pursuant to 26 U.S.C. s. 6104(d)(3) before submission. This information is found on Schedule B of the IRS Form 990.

Financial statement (enclosed) – Financial statements from organizations that receive at least $500,000 but less than $1 million in annual contributions must be audited or reviewed by an independent certified public accountant. Financial statements from organizations that receive $1 million or more in annual contributions must be audited by an independent certified public accountant.

FDACS-10100 Rev. 01/15 Page IV of VII

Organizations may request a 180 day extension for filing of financial documents. Failure to provide financial documents within the 180 extension period will result in automatic suspension of your registration. [s. 496.407(1), (3), F.S.]

Item #27

Indicate by checking the appropriate box if a copy of the signed CPA review or audit is attached. [s. 496.407(1)(d), F.S.]

Item #28

If a sponsor, answer questions a – d as directed.

Item #29

Provide the name and contact information for the person responsible for completing the application.

PARENT ORGANIZATIONS / PARENT SPONSORS

You must submit financial statements for the parent organization and each chapter, branch, or affiliate listed in question #8a or in the Supplemental Consolidated Financial Statement on the Registration Application. However, if all contributions received by the chapters, branches, or affiliates are remitted directly into a depository account which feeds directly into the parent organization’s centralized accounting system from which all disbursements are made, the parent organization may submit one consolidated financial statement or IRS form 990 with all attachments, or form 990-EZ and Schedule O. Please complete the financial statement as a consolidated financial statement (i.e. the financial information for all branches should be combined with the main parent organization into a single financial statement upon which one registration fee will be based). Additionally, an individual tax return or financial statements must be submitted for each chapter, branch, or affiliate that is required to file such forms.

IMPORTANT: Every charitable organization or sponsor which is required to register under s. 496.405, F.S., or is exempt under s. 496.406(1)(d) shall conspicuously display the following statement on every solicitation, confirmation, receipt, or reminder of a contribution: “A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.” The statement must include a toll-free number and website for the division that can be used to obtain the registration information. When the solicitation consists of more than one piece, the statement must be displayed prominently in the solicitation materials. If the solicitation occurs on a website, the statement must be conspicuously displayed on any webpage that identifies a mailing address where contributions are to be sent, identifies a telephone number to call to process contributions, or provides for online processing of contributions. NOTE: It is not required to post the disclosure statement on every page of a website. The toll-free number of the department is 1-800-HELP-FLA (435-7352) or (850) 410-3800. The department’s website is www.FreshFromFlorida.com.

REGISTRATION FEES FOR CHARITABLE ORGANIZATIONS/SPONSORS [s. 496.405(4)(a), F.S.]

GUIDE FOR CALCULATING FEES:

Due to the diversity in reporting practices, this should only be used as a guide.

When submitting lists for clarification, acronyms and abbreviations should not be used.

Duly registered 501(c) entities may be determined by accessing the Gift Givers’ Guide at www.FreshFromFlorida.com.

Pursuant to s. 496.404(5), F.S., “Contribution” means the promise, pledge, or grant of any money or property, financial assistance, or any other thing of value in response to a solicitation. “Contribution” includes, in the case of a charitable organization or sponsor offering goods and services to the public, the difference between the direct cost of the goods and services to the charitable organization or sponsor and the price at which the charitable organization or sponsor or any person acting on behalf of the charitable organization or sponsor resells those goods or services to the public.

FDACS-10100 Rev. 01/15 Page V of VII

“Contribution” does not include bona fide fees, dues, or assessments paid by members, provided that membership is not conferred solely as consideration for making a contribution in response to a solicitation. “Contribution” also does not include funds obtained by a charitable organization or sponsor pursuant to government grants or contracts, or obtained as an allocation from a United Way organization that is duly registered with the department or received from an organization that is exempt from federal income taxation under s. 501(a) of the Internal Revenue Code and described in s. 501(c) of the Internal Revenue Code that is duly registered with the department.

Contributions may be from the following sources:

∙public;

∙in-kind non-cash values;

∙federated campaign revenues less revenues received from a duly registered 501(c) (a list should be submitted including complete name and amounts);

∙“pass through” revenues less revenues received from a duly registered 501(c) (a list should be submitted including complete name and amounts);

∙net from fundraising events;

∙related organizations less revenues from a duly registered 501(c) (a list should be submitted including complete name and amounts);

∙net program service revenue (program service revenue minus revenue from government contracts, i.e. medicare, medicaid, less program service expense);

∙royalties;

∙net rent less rents received from a duly registered 501(c) (a list should be submitted including complete name and amounts);

∙net revenue from sale of donated assets;

∙net revenue from gaming;

∙net from sale of inventory;

∙other miscellaneous revenues.

Non-contributions may be from the following sources:

∙revenues from duly registered 501(c) entities (a list should be submitted including complete name and amounts);

∙membership dues;

∙revenues from direct government grants (a list should be submitted including complete name and amounts);

∙revenues from government contracts (a list should be submitted including complete name and amounts);

∙dividends, interests, etc.;

∙sale of assets from investments.

For contributions received the preceding fiscal year:

		Fee
a.	Less than $5,000 with or without paid officers	$	10
b.	$25,000 or less, no compensated employees, no part of the assets or income inures	$	10
	to the benefit of any officer or member, or no professional solicitors/consultants
c.	$5,000 or more, but less than $100,000	$	75
d.	$100,000 or more, but less than $200,000	$	125
e.	$200,000 or more, but less than $500,000	$	200
f.	$500,000 or more, but less than $1,000,000	$	300
g.	$1,000,000 or more, but less than $10,000,000	$	350
h.	$10,000,000 or more	$	400

Note: A parent organization or sponsor filing on behalf of one or more chapters, branches, or affiliates shall total all contributions received by them to determine registration fees.

FDACS-10100 Rev. 01/15 Page VI of VII

All documents and attachments submitted with this application are subject to public review pursuant to Chapter 119, F.S. PLEASE TYPE OR PRINT. Additional pages may be attached if additional space is needed using the same format. Please ensure that all attachments reflect the organization’s name or registration number and the number of the corresponding question. All fees are non-refundable.

Business Information

*Fictitious (DBA) Name:

*If you are a Florida organization, all fictitious names must be registered with the Florida Department of State, Division of Corporations. If business is a corporation then ‘Name’ is the legal name of the business as listed with the Division of Corporations.

Other Names Soliciting As:

2.Street Address (include APT or SUITE # in all address lines; addresses must match those filed with the Division of Corporations; do not use a mail drop):

City:														State:			Zip Code:
																-
Mailing Address (if different from above):
City:														State:			Zip Code:
																-
		Telephone Number:						Fax Number:
3.
(		)		-			(	)				-
Email Address for Organization:									Website:

FDACS-10100 Rev. 01/15 Page 1 of 11

7.List all officers, directors, trustees, and principal salaried executive personnel: Exemptions from public records apply to certain personal information about current or former - law enforcement officers, judges, prosecutors, public defenders, firefighters, code enforcement officers, guardians ad litem and their families. For a complete list of exemptions, see

s. 119.071(4), F.S. If you qualify for one of these exemptions, please do not list your residence address and phone number. [s. 496.405(2)(g)2, F.S., s. 496.405(d)(5), (6), F.S.] (attach additional sheets as necessary using the same format)

Name:

Title:

Street Address:

City:

City:

State:

Zip Code:

State:

Zip Code:

-

-

Telephone Number:

Compensated?

Telephone Number:

Compensated?

(

)

-

 Yes

 No

(

)

-

 Yes

 No

Criminal History:

 Yes

 No

Criminal History:

 Yes

 No

Exempt from public records [s. 119.071(4), F.S.]

 Yes

 No

Exempt from public records [s. 119.071(4), F.S.]  Yes

 No

Name:

Name:

Title:

Title:

Street Address:

Street Address:

City:

City:

State:

Zip Code:

State:

Zip Code:

-

-

Telephone Number:

Compensated?

Telephone Number:

Compensated?

(

)

-

 Yes

 No

(

)

-

 Yes

 No

Criminal History:

 Yes

 No

Criminal History:

 Yes

 No

Exempt from public records [s. 119.071(4), F.S.]

 Yes

 No

Exempt from public records [s. 119.071(4), F.S.]  Yes  No

Name:

Name:

Title:

Title:

Street Address:

Street Address:

City:

City:

State:

Zip Code:

State:

Zip Code:

-

-

Telephone Number:

Compensated?

Telephone Number:

Compensated?

(

)

-

 Yes

 No

(

)

-

 Yes

 No

Criminal History:

 Yes

 No

Criminal History:

 Yes

 No

Exempt from public records [s. 119.071(4), F.S.]

 Yes

 No

Exempt from public records [s. 119.071(4), F.S.]  Yes

 No

FDACS-10100 Rev. 01/15 Page 2 of 11

8a. List all branch offices, chapters or affiliates located in the state of Florida. If you are a parent organization that submits a consolidated financial statement, you may skip Question 8a. and list your branches and affiliates on the Supplemental Consolidated Financial Statement on page 11.

[s. 496.405(2)(g)1, F.S.]

Name:

Name:

Street Address:

Street Address:

City:

City:

State:

Zip Code:

State:

Zip Code:

-

-

Telephone Number:

Telephone Number:

(

)

-

(

)

-

Email:

Email:

8b. If the charitable organization or sponsor does not maintain an office in Florida, provide the name, street address, and telephone number of the person having custody of the financial records.

Name:

Title:

Address:

City:

State:

Zip Code:

-

Telephone Number:

Email:

(

)

-

9. List name of the individuals or officers who are in charge of any solicitation activities: [s. 496.405(2)(c), F.S.]

Name:	Street Address:			Telephone Number:
Name:	Street Address:			Telephone Number:

Criminal History:  Yes  No

10.List the name, address, and telephone number(s) of person(s) responsible for the custody and final distribution of contributions: [s. 496.405(2)(g)5, F.S.]

Name:

Street Address:

Telephone Number:

Name:

Street Address:

Telephone Number:

Criminal History:

 Yes  No

Month/Day fiscal year ends: [s. 496.405(2)(g)3, F.S.]

/

11.

Month

Day

FDACS-10100 Rev. 01/15 Page 3 of 11

12. Has your organization been granted tax exempt status by the Internal Revenue Service? [s. 496.405(2)(f), F.S.]

 Yes	501(c)__________ If yes, you must attach a copy of the tax exemption determination letter from the IRS.
	(insert number)

No

Pending (tax exemption determination letter must be submitted with renewal or 30 days after receipt)

Revoked

13.What is the purpose for which the organization is organized? (Briefly and concisely explain the purpose for which your organization was created. It is best to summarize this information in your own words. Use only the space provided.) [s. 496.405(2)(b), F.S.]

14.What is the purpose for which the contributions will be used? (Briefly and concisely explain the purpose for which contributions will be used. Use only the space provided. Do not reference 990 or include an attachment.) [s. 496.405(2)(b), F.S.]

16. Does the charitable organization or sponsor employ a professional solicitor? [s. 496.405(2)(e), F.S.]

 Yes No	If yes, attach a copy of the current contract, and provide the following information for each.
	(attach additional sheets as necessary using the same format)

Name:

Address:

City:

State:

Zip Code:

-

Telephone Number:

Florida Registration Number:

(

)

-

SS-

Dates of contract:

/

/

/

/

Beginning Date:

End Date:

Month

Day

Year

Month

Day

Year

17. Does the charitable organization or sponsor employ a professional fundraising consultant? [s. 496.405(2)(e), F.S.]

 Yes No	If yes, attach a copy of the current contract, and provide the following information for each.
	(attach additional sheets as necessary using the same format)
Name:
Address:
City:	State:	Zip Code:

-

FDACS-10100 Rev. 01/15 Page 4 of 11

Telephone Number:

Florida Registration Number:

(

)

-

FC-

Dates of contract:

/

/

/

/

Beginning Date:

End Date:

Month

Day

Year

Month

Day

Year

18. Does the charitable organization or sponsor utilize a commercial co-venturer? [s. 496.405(2)(e), F.S.]

 Yes

No

If yes, attach a copy of the current contract, and provide the following information for each.

(attach additional sheets as necessary using the same format)

Name:

Address:

City:

State:

Zip Code:

-

Telephone Number:

(

)

-

Dates of contract:

/

/

/

/

Beginning Date:

End Date:

Month

Day

Year

Month

Day

Year

NOTE: Any change to the responses provided to Questions 19-24 must be reported to the department within 10 days after the change occurs. (s. 496.405(1)(b), F.S.) The Solicitation of Contributions Material Change Form, FDACS-10118, Rev. 01/15, as incorporated in Rule 5J-7.004(5), F.S., This form can be found online at www.FreshFromFlorida.com.

19.Is this charitable organization/sponsor authorized by any other state to solicit contributions? [s. 496.405(2)(d)1, F.S.]

 Yes No

20.Has the charitable organization/sponsor entered into an assurance of voluntary compliance (AVC)

or agreement similar to that set forth in s. 496.420, Florida Statutes in any jurisdiction? (This is not common.)

[s. 496.405(2)(d)4, F.S.]

 Yes No

If yes, attach a copy of the agreement.

21.Has the charitable organization or sponsor or any of its officers, directors, trustees, or employees, regardless of adjudication, been convicted of, or found guilty of, or pled guilty or nolo contendere to, or been incarcerated within

the last 10 years as a result of having previously been convicted of, or found guilty of, or pled guilty or nolo contendere to, any felony within the last 10 years? [s. 496.405(2)(d)5, F.S.]

	 Yes No	If yes, please provide the following information for each individual: (attach additional sheets as necessary using the
		same format)
Name:
Nature of offense:					Date:	/		/
Court having jurisdiction:					Month		Day		Year
Disposition of offense:					Date:	/		/
					Month		Day		Year
Does this individual engage in solicitation activities?			 Yes  No

FDACS-10100 Rev. 01/15 Page 5 of 11

22.Has the charitable organization/sponsor or any of its officers, directors, trustees, or employees, regardless of adjudication, been convicted of, or found guilty of, or pled guilty or nolo contendere to, or been incarcerated within the last 10 years as a result of having previously been convicted of, or found guilty of, or pled guilty or nolo contendere to, any crime involving fraud, theft, larceny, embezzlement, fraudulent conversion, misappropriation of

property, or any crime enumerated in this chapter or resulting from acts committed while involved in the solicitation of contributions within the last 10 years? [s. 496.405(2)(d)6, F.S.]

Yes No If yes, please provide the following information for each individual: (attach additional sheets as necessary using the same format)

Name:

Nature of offense:				Date:	/		/
Court having jurisdiction:				Month		Day		Year
Disposition of offense:				Date:	/		/
				Month		Day		Year
Does this individual engage in solicitation activities?		 Yes  No

23.Has the charitable organization/sponsor or any of its officers, directors, trustees, or principal salaried executive personnel been enjoined in any jurisdiction from soliciting contributions or been found to have engaged in

unlawful practices in the solicitation of contributions or administration of charitable assets?

[s. 496.405(2)(d)2,(2)(d)7, F.S.]

 Yes No	If yes, please provide the following information for each individual (attach additional sheets as necessary using the
	same format).
Name:
Court issuing the injunction:			Date of injunction:
				/			/
			Month		Day			Year

24.Has the charitable organization/sponsor had its registration or authority denied, suspended, or revoked by any governmental agency? [s. 496.405(2)(d)3, F.S.]

 Yes No

If yes, please explain the reasons for the denial, suspension or revocation:

25. I have attached the conflict of interest annual certification to this registration application. [s. 496.4055, F.S.]

26.Indicate the type of financial statement you are filing for the immediately preceding fiscal year ending

___/___/_____: [s. 496.405(2)(a), F.S.]

Budget (newly formed organizations only)

Department’s financial statement form - See pages 8-10

990 and all attachments - See item #26 of instructions for completing the Financial Statement

990-EZ and Schedule O - See item #26 of instructions for completing the Financial Statement

180 Day Extension requested for financial statement only. (Failure to file a financial statement within the 180 days will result in an automatic suspension of your registration.) [s. 496.405(1)(d)2, F.S.]

27.Charitable organizations or sponsors that receive at least $500,000 in annual contributions must have their financial statement reviewed or audited by an independent certified public accountant. If annual contributions are more than $1 million, then the financial statement must be audited by an independent certified public accountant. [s. 496.407(1)(d), F.S.]

Attached is a copy of signed CPA review or audit

 Yes  No

FDACS-10100 Rev. 01/15 Page 6 of 11

ONLY SPONSORS NEED TO ANSWER THE FOLLOWING QUESTIONS:

“Sponsor” means a group or person who is or holds herself or himself out to be soliciting contributions by the use of a name that implies that the group or person is in any way affiliated with or organized for the benefit of emergency service employees or law enforcement officers and the group or person is not a charitable organization. The term includes a chapter, branch, or affiliate that has its principal place of business outside the state if such chapter, branch, or affiliate solicits or holds itself out to be soliciting contributions in this state.

28. Answer the following: [s. 496.426, F.S.]

a.Does the organization consist of members who are individuals of whom at least 10% or 100 members, whichever is less, are actively employed as law enforcement officers or emergency service employees by an agency of the United States, this state, a municipality, or a political subdivision of this state, and who personally sign written membership agreements with the organization and pay an annual membership of not less than $10 a member?

 Yes  No

b.Total number of sponsor’s members:

c.Total number of members actively employed as law enforcement or emergency service employees:

d.Percentage of total net contributions, which are dispersed in the state on behalf of its members in furtherance of its stated purposes or programs (defined as the total amount of all contributions raised minus the total cost of

expenses incurred in raising contributions solicited):		%
CONTACT PERSON

29. Contact person for the charitable organization or sponsor:

Name:Title:

Telephone Number:							Email Address:
(	)			-

				CERTIFICATION
I,			, am the			,
		Name			Title
completing the application for
					Name of Organization or Company
And further state as follows:			(Please check all that apply)

I have read the registration application and know the contents thereof; and

The registration application is made for the purpose of complying with the provisions of Chapter 496, Florida Statutes, Solicitation of Contributions Act

I certify that I am authorized to complete this registration application and that the information provided is true and accurate.

SignaturePrinted NameDate

(		)		-
	Telephone Number						Email Address

FDACS-10100 Rev. 01/15

Page 7 of 11

FINANCIAL STATEMENT

FOR FISCAL YEAR ENDING ________ / _______ / ________

(Please use department material change form if your organization’s fiscal year ending changes.)

	CH			DTN
NAME OF CHARITABLE ORGANIZATION			FOR	RENEWALS
Is this a consolidated financial statement for chapters, branches, or affiliates?  Yes			 No

NOTE: In lieu of using this financial statement you may send the IRS Form 990 and all attached schedules or the IRS Form 990EZ and Schedule O.

** IRS 990N E-Postcard and IRS 990-PF are not acceptable Financial Statements.

REVENUE
1.	Federated campaigns:	1. __________________
(must provide a list of sources and amounts)
2.	Government grants:	2. __________________
(must provide a list of sources and amounts)
3.	Program service revenue:	3. __________________
4.	Membership dues:	4. __________________
5.	Income from interest, dividends, etc.	5. __________________
6.	Income from investments & tax-exempt bond proceeds:	6. __________________
7.	Sale of assets other than inventory:
	a. Gross sales	7a. ________________
	b. Less sales expenses	7b. ________________
	c. Net gain or (loss) from sale of assets	7c. _________________
8.	In-kind contributions (non-cash contributions):	8. _________________
9.	Royalties:	9. _________________
10.	Related organizations: (Must provide a list of sources and amounts)	10. _________________
11.	Net rental income:	11. _________________
12.	Sales of inventory:
	a. Gross sales	12a. ________________
	b. Less: costs of goods sold	12b. ________________
	c. Net income or (loss) from inventory sales	12c. ________________
13. Income from fundraising events:
	a. Gross	13a. ________________
	b. Less: direct expenses	13b. ________________
	c. Net income or (loss) from fundraising events	13c. ________________
14. Income from gaming activities:
	a. Gross	14a. ________________
	b. Less: direct expenses	14b. ________________
	c. Net income or (loss) from gaming activities	14c. ________________
15.	All other contributions, gifts, grants & similar amounts:	15. _________________
16. TOTAL REVENUE		16. _________________
(Add lines 1,2, 3, 4, 5, 6, 7c, 8, 9, 10, 11, 12c, 13c, 14c & 15)

FDACS-10100 Rev. 01/15

Page 8 of 11

Statement of Functional Expenses for ________________ ____							______		CH ___________
		(Organization Name)							(Renewals Only)
ITEMS	(A) Program Services	(B) Management & General			( C )		Fundraising		TOTAL for A,B, C
Grants & allocations
Cash_____
Non Cash______
Attach schedule
Assistance to individuals
Benefits to or for members
Compensation to officers, etc.
Other salaries, wages, etc.
Fees for service non employee
Other benefits, pensions, etc.
Payroll taxes
Professional fundraising fees
Investment management fees
Accounting fees
Management
Legal fees
Lobbying
Office supplies
Telephone
Postage & shipping
Equipment rental
Occupancy
Printing
Travel
Conferences & meetings
Interest
Insurance
Advertising & promotions
Information technology
Royalties
Payments to affiliates
Depreciation, depletion &
amortization
Other (List Item)
Other (List Item)
Other (List Item)
TOTAL EXPENSES	(A)	(B)			(C )				TOTAL