Charity Registration Form

CHARITY REGISTRATION FORM

This Charity Registration Form must be completed by the authorized representative of the charitable organization seeking registration. The information provided herein will be relied upon for official records and for determining compliance with applicable statutory requirements. False or misleading statements may subject the organization and its officers to administrative or civil penalties.

1. Organization Identification

2. Entity Type

Select the legal form of the organization (check all that apply):

Corporation (Nonprofit) Trust Unincorporated Association Foundation Other:

3. Governance and Board

Articles of Incorporation / Establishment Bylaws or Trust Instrument Most Recent Financial Statements Conflict of Interest Policy Current Board List Other attachments (describe below)

4. Purpose, Activities and Beneficiaries

5. Financial Overview

Does the organization engage in the following fundraising activities? (check all that apply)

Direct solicitations / Donations Grants from foundations or public agencies Special events / fundraising events Membership dues Other fundraising activities (specify below)

6. Compliance, Policies and Certifications

The undersigned certifies, under penalty of law, that the information contained in this form and the accompanying documentation is true, correct and complete to the best of the signer's knowledge. The organization agrees to comply with applicable reporting, recordkeeping and disclosure obligations, and authorizes inspection of records as permitted by law.

By signing below, the authorized representative acknowledges that registration does not confer tax-exempt status and that any representations regarding tax treatment must be supported by the organization's governing instruments and applicable determinations.

Yes No

7. Acknowledgment and Governing Law

The organization acknowledges that submission of this form creates a record for official review. The organization agrees that any disputes arising from the registration, interpretation or enforcement of applicable registration obligations shall be governed by the laws of the jurisdiction in which the organization principally conducts activities, without regard to conflict of law principles.

Entire Agreement: This form and the attachments constitute the complete registration submission. No other statements, whether oral or written, modify or supplement the representations and certifications provided herein unless executed in writing by an authorized representative of the registering organization and the registering authority.

8. Attachments Checklist

Attach copies of the following as applicable. Mark those provided and list any additional documents.

Articles of Incorporation / Trust Instrument Bylaws or Governance Documents Latest Financial Statements Current List of Board Members Other documents (describe below)

9. Declaration of Authorized Representative

I hereby certify that I am an authorized officer or agent of the organization named in this registration, that I am authorized to submit this registration on the organization's behalf, and that the information contained in this form and its attachments is true, correct and complete to the best of my knowledge.

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