Form DBO-CSCL119 "Nonprofit Community Service Organization Audit Report and Declaration" - California

What Is Form DBO-CSCL119?

This is a legal form that was released by the California Department of Financial Protection and Innovation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest edition provided by the California Department of Financial Protection and Innovation;
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  • Fill out the form in our online filing application.

Download a fillable version of Form DBO-CSCL119 by clicking the link below or browse more documents and templates provided by the California Department of Financial Protection and Innovation.

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Download Form DBO-CSCL119 "Nonprofit Community Service Organization Audit Report and Declaration" - California

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STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
NONPROFIT COMMUNITY SERVICE ORGANIZATION AUDIT REPORT
AND DECLARATION
DBO–CSCL 119 (Rev. 12-17)
Fee: None
DEPARTMENT OF BUSINESS OVERSIGHT
Insert File Number of Previous Filings
Before the Department (if known)
COMMISSIONER OF
BUSINESS OVERSIGHT
STATE OF CALIFORNIA
NONPROFIT COMMUNITY SERVICE ORGANIZATION
AUDIT REPORT AND DECLARATION
SECTIONS 12104(i) AND 12104(j) OF THE CHECK SELLERS, BILL PAYERS AND PRORATERS LAW
(Financial Code Sections 12104(i) and 12104(j))
A.
Information on the Nonprofit Community Service Organization
1.
Name of Nonprofit Community Service Organization:
If Name Has Changed Since a Previous Filing, Prior Name:
2.
Address of Nonprofit Community Service Organization
Number and Street
City
State
Zip Code
Mailing Address:
Number and Street
City
State
Zip Code
3.
Area Code and Telephone Number
: (
)
4.
Contact Person
:
B.
Attached is the audit report required pursuant to Section 12104(i). (Attach audit report.)
The audit report covers the calendar year for
(insert year).
OR
The audit report covers the fiscal year beginning
and ending
(insert the beginning and ending dates of the fiscal year).
C.
Declaration
The nonprofit community service organization named hereunder is in compliance with Section 12104 of the Check Sellers,
Bill Payers and Proraters Law (Financial Code Section 12104), and by signing below I certify (or declare) under penalty of
perjury under the laws of the State of California that this statement is true and correct.
Date
Place of Execution
Name of Authorized Individual
Signature
Title of Authorized Individual
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
NONPROFIT COMMUNITY SERVICE ORGANIZATION AUDIT REPORT
AND DECLARATION
DBO–CSCL 119 (Rev. 12-17)
Fee: None
DEPARTMENT OF BUSINESS OVERSIGHT
Insert File Number of Previous Filings
Before the Department (if known)
COMMISSIONER OF
BUSINESS OVERSIGHT
STATE OF CALIFORNIA
NONPROFIT COMMUNITY SERVICE ORGANIZATION
AUDIT REPORT AND DECLARATION
SECTIONS 12104(i) AND 12104(j) OF THE CHECK SELLERS, BILL PAYERS AND PRORATERS LAW
(Financial Code Sections 12104(i) and 12104(j))
A.
Information on the Nonprofit Community Service Organization
1.
Name of Nonprofit Community Service Organization:
If Name Has Changed Since a Previous Filing, Prior Name:
2.
Address of Nonprofit Community Service Organization
Number and Street
City
State
Zip Code
Mailing Address:
Number and Street
City
State
Zip Code
3.
Area Code and Telephone Number
: (
)
4.
Contact Person
:
B.
Attached is the audit report required pursuant to Section 12104(i). (Attach audit report.)
The audit report covers the calendar year for
(insert year).
OR
The audit report covers the fiscal year beginning
and ending
(insert the beginning and ending dates of the fiscal year).
C.
Declaration
The nonprofit community service organization named hereunder is in compliance with Section 12104 of the Check Sellers,
Bill Payers and Proraters Law (Financial Code Section 12104), and by signing below I certify (or declare) under penalty of
perjury under the laws of the State of California that this statement is true and correct.
Date
Place of Execution
Name of Authorized Individual
Signature
Title of Authorized Individual
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
NONPROFIT COMMUNITY SERVICE ORGANIZATION AUDIT REPORT
AND DECLARATION
DBO–CSCL 119 (Rev. 12-17) Page 2 of 4
Section 12104(i) of the California Financial Code provides that a nonprofit community service organization shall submit to
the Commissioner of Business Oversight an audit report containing audited financial statements covering the calendar
year or, if the organization has an established fiscal year, then for that fiscal year, within 120 days after the close of the
calendar or fiscal year.
Section 12104(j) provides that a nonprofit community service organization shall submit a
declaration executed by an official authorized by the board of the organization stating that the organization complies with
the provisions of Section 12104 of the California Financial Code.
NONPROFIT COMMUNITY SERVICE ORGANIZATION
AUDIT REPORT AND DECLARATION INSTRUCTIONS
Section 12104(i) of the Check Sellers, Bill Payers and Proraters Law provides that a nonprofit community service
organization shall submit to the Commissioner an audit report containing audited financial statements covering the
calendar year or, if the organization has an established fiscal year, then for that fiscal year, within 120 days after the close
of the calendar or fiscal year. Section 12104(j) provides that a nonprofit community service organization shall submit a
declaration executed by an official authorized by the board of the organization stating that the organization complies with
the provisions of Section 12104 of the California Financial Code. This form is to provide the audit report and the required
declaration to the Commissioner.
Item 1.
Provide the name of the nonprofit community service organization claiming the exemption from licensure. If
you are filing an amended notice and your name has changed since your original notice was filed, provide your new name
on the first line and your previous name on the second line.
Item 2.
Provide the address of the organization. If you have a different mailing address, provide the mailing address
on the second line.
Item 3. Provide the organization’s area code and telephone number.
Item 4. Provide the name of a contact person within the organization.
Item B. Select the appropriate notification by marking within the parentheses. If the audit report covers the calendar
year, insert the calendar year that the audit report covers. If the audit report covers the fiscal year, insert both the
beginning and ending dates of the fiscal year. Be sure to include the year in the date provided.
Item C.
On the line above the applicable description, provide the date of signature, the name of the authorized
individual signing the declaration on behalf of the organization, the place where the declaration was signed (city and
state), the signature of the individual, and the title of the individual.
Attachments
Attach audit report.
Filing Information
When to file:
Section 12104(i) of the Check Sellers, Bill Payers and Proraters Law requires a nonprofit community service
organization to submit to the Commissioner an audit report containing audited financial statements within 120 days after
the close of the calendar or fiscal year.
Where to file:
To file the form with the Commissioner, send the form and the accompanying documents to the Department’s Sacramento
Office:
Department of Business Oversight
1515 K Street, Suite 200
Sacramento, CA 95814-4052
Attention: Program Support
Filing Fee: This form does not require a filing fee.
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
NONPROFIT COMMUNITY SERVICE ORGANIZATION AUDIT REPORT
AND DECLARATION
DBO–CSCL 119 (Rev. 12-17) Page 3 of 4
NOTICES REQUIRED UNDER STATE AND FEDERAL LAW I.
INFORMATION PRACTICES ACT OF 1977
(California Civil Code Section 1798.17)
(a) The Department of Business Oversight of the State of California, is
requesting the information specified in the application for registration, qualification, a
certificate or a license.
(b) The Deputy Commissioner, Office of Management and Budget, 1515 K
Street, Suite 200, Sacramento, California, 95814, telephone (916) 445-5541, is
responsible for the system of records and shall, upon request, inform individuals
regarding the location of the Department of Business Oversights' records and the
categories of persons who use the information in the records.
(c) The records are maintained pursuant to one or more of the following laws:
the Corporate Securities Law of 1968 (Corporations Code Section 25000, et seq.); the
Capital Access Company Law (Corporations Code Section 28000, et seq.); the Bucket
Shop Law (Corporations Code Section 29000, et seq.); the California Commodity Law of
1990 (Corporations Code Section 29500, et seq.); the Franchise Investment Law
(Corporations Code Section 31000, et seq.); the Check Sellers, Bill Payers and Proraters
Law (Financial Code Section 12000, et seq.); the California Deferred Deposit
Transaction Law (Financial Code Section 23000, et seq.); the Escrow Law (Financial
Code Section 17000, et seq.); the California Financing Law (Financial Code Section
22000, et seq.); the Securities Depository Law (Financial Code Section 30000, et seq.);
and the California Residential Mortgage Lending Act (Financial Code Section
50000, et seq.).
(d) The submission of all items of information is mandatory unless otherwise
noted. Section 17520 of the Family Code requires the Department of Business
Oversight to collect social security numbers from all applicants. The Privacy Act of 1974
prohibits a state agency from denying an individual any right, benefit or privilege
provided by law because of the individual’s refusal to disclose the individual’s social
security account number.
(e) Failure to provide all or any part of the information requested may preclude
the Department of Business Oversight from approving the application.
(f) The principal purposes within the Department of Business Oversight for which
the information is to be used are to determine whether (1) a license, qualification,
registration, certificate or other authority should be accepted, granted, approved, denied,
revoked or limited in any way; (2) business entities or individuals licensed or otherwise
regulated by the Department of Business Oversight are conducting themselves in
accordance with applicable laws; and/or (3) laws administered by the Department of
Business Oversight are being or have been violated and whether administrative action, civil
action, or referral to appropriate federal, state or local law enforcement or regulatory
agencies, or to a self-regulatory organization, as authorized by law, is appropriate.
(g) Any known or foreseeable disclosures of the information pursuant to subdivision
(e) or (f) of Civil Code Section 1798.24 may include transfers to other federal, state, or local
law enforcement or regulatory agencies, or to a self-regulatory organization, as authorized
by law.
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
NONPROFIT COMMUNITY SERVICE ORGANIZATION AUDIT REPORT
AND DECLARATION
DBO–CSCL 119 (Rev. 12-17) Page 4 of 4
(h) Subject to certain exceptions or exemptions, the Information Practices Act grants an
individual a right of access to personal information concerning the requesting individual that is
maintained by the Department of Business Oversight.
II. FEDERAL PRIVACY ACT OF 1974 (Public Law 93-579)
In accordance with Section 7 of the Privacy Act of 1974 (found at 5 U.S.C. §
552a note (Disclosure of Social Security Number)), the following is information on whether the
disclosure of a social security account number is voluntary or mandatory, by what statutory or
other authority such number is solicited, and what uses will be made of it.
(1) Section 17520 of the Family Code requires the Department of Business Oversight to
collect social security numbers from all applicants. The Privacy Act of 1974 prohibits a state
agency from denying an individual any right, benefit or privilege provided by law because of the
individual’s refusal to disclose the individual’s social security account number.
(2) A social security account number is solicited pursuant to one or more of the
following authorities: the Corporate Securities Law of 1968 (Corporations Code Section
25000, et seq.); the Capital Access Company Law (Corporations Code Section 28000,
et seq.); the Bucket Shop Law (Corporations Code Section 29000, et seq.); the
California Commodity Law of 1990 (Corporations Code Section 29500, et seq.); the
Franchise Investment Law (Corporations Code Section 31000, et seq.); the Check
Sellers, Bill Payers and Proraters Law (Financial Code Section 12000, et seq.); the
Escrow Law (Financial Code Section 17000, et seq.); the California Financing Law
(Financial Code Section 22000, et seq.); the California Deferred Deposit Transaction
Law(Financial Code Section 23000, et seq.); the Securities Depository Law (Financial
Code Section 30000, et seq.); the California Residential Mortgage Lending Act
(Financial Code Section 50000, et seq.); and the regulations adopted thereunder, as
well as Section 17520 of the Family Code.
(3) For all persons disclosing a social security account number, the number may
be used, in addition to other information provided, to conduct a background investigation
of the individual by the Department of Justice's Identification and Information Branch or
by other federal, state or local law enforcement agencies, or a self-regulatory
organization, as authorized by law. The social security number may also be used to
respond to requests for this number made by child support agencies.
III. THE PERMIT REFORM ACT OF 1981
(Government Code Section 15378(b))
The Department of Business Oversight has established time periods for
processing an application from the receipt of the initial application to the final application
decision. An applicant may appeal directly to the Business, Transportation & Housing
Agency for a timely resolution of any dispute arising from a violation of the time periods.
Information regarding the appeal process may be found in Title 21, Chapter 6 of the
California Code of Regulations, entitled Regulations Relating to Appeals Under the
Permit Reform Act of 1981.
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