Form SFN11300 "Charitable Organization Registration Statement" - North Dakota

Form sfn11300 or the "Charitable Organization Registration Statement" is a form issued by the North Dakota Secretary of State.

Download a PDF version of the Form sfn11300 down below or find it on the North Dakota Secretary of State Forms website.

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Download Form SFN11300 "Charitable Organization Registration Statement" - North Dakota

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CHARITABLE ORGANIZATION
For Office Use Only
REGISTRATION STATEMENT
ID Number:
SECRETARY OF STATE
WO Number:
SFN 11300 (07-2016)
License Number:
Issued By:
FEE: $25.00
Secretary of State
ATTACHMENTS:
State of North Dakota
600 E Boulevard Ave Dept 108
IRS Determination Letter (or first page of pending application)
Bismarck ND 58505-0500
Telephone: (701) 328-3665
Financial State or IRS Form 990
Toll-Free: (800) 352-0867, option 8
List of names and addresses of all directors, officers, and trustees. Indicate the individuals having the
Website:
sos.nd.gov
financial discretion or authority as to the distribution and use of contributions received.
List of total compensation, including salaries, fees, bonues, fringe benefits, severance payments, and
deferred compensation, paid to all employees by the charitable organization and all its affiliated
organizations.
Copy of agreement with professional fundraiser, if any.
SEE INSTRUCTIONS FOR FILING AND MAILING INFORMATION.
TYPE OR PRINT LEGIBLY
For reference, see North Dakota Century Code, Chapter 50-22.
1A. Legal name of organization
1B. Federal ID number
1C. Name(s) under which the organization solicits contributions
1D. Street and mailing address of principal executive office (street/RR, PO box, city, state, ZIP+4) Street address MUST be provided; may not be only a post
office box.
City
State
ZIP code
Telephone number
2A. Registrant is a(n)
Unincorporated nonprofit association
Nonprofit corporation
Nonprofit limited liability company
Trust
2B. State of origin
2C. Year organized
2D. Is the organization exempt from state income tax?
Yes
No
2E. Is the organization exempt from federal income taxes? If yes, attach a copy of your IRS determination letter. If the application is pending, attach a copy of
the first page of the application.
Yes - Provide status: 501(c)(
)
No
Application pending
3. Method(s) of soliciting the organization anticipates using (check all that apply to your organization)
Direct mail
Grant writing
Local television
Telemarketing
Magazines or periodicals
Personal contact
Radio
Show or concert
Newspaper
Membership enrollment
Vending business
National television
Other - Describe:
4. Period of time during which solicitation is to be conducted
5. General purposes for which organized
6. General purposes for which contributions to be solicited will be used
CHARITABLE ORGANIZATION
For Office Use Only
REGISTRATION STATEMENT
ID Number:
SECRETARY OF STATE
WO Number:
SFN 11300 (07-2016)
License Number:
Issued By:
FEE: $25.00
Secretary of State
ATTACHMENTS:
State of North Dakota
600 E Boulevard Ave Dept 108
IRS Determination Letter (or first page of pending application)
Bismarck ND 58505-0500
Telephone: (701) 328-3665
Financial State or IRS Form 990
Toll-Free: (800) 352-0867, option 8
List of names and addresses of all directors, officers, and trustees. Indicate the individuals having the
Website:
sos.nd.gov
financial discretion or authority as to the distribution and use of contributions received.
List of total compensation, including salaries, fees, bonues, fringe benefits, severance payments, and
deferred compensation, paid to all employees by the charitable organization and all its affiliated
organizations.
Copy of agreement with professional fundraiser, if any.
SEE INSTRUCTIONS FOR FILING AND MAILING INFORMATION.
TYPE OR PRINT LEGIBLY
For reference, see North Dakota Century Code, Chapter 50-22.
1A. Legal name of organization
1B. Federal ID number
1C. Name(s) under which the organization solicits contributions
1D. Street and mailing address of principal executive office (street/RR, PO box, city, state, ZIP+4) Street address MUST be provided; may not be only a post
office box.
City
State
ZIP code
Telephone number
2A. Registrant is a(n)
Unincorporated nonprofit association
Nonprofit corporation
Nonprofit limited liability company
Trust
2B. State of origin
2C. Year organized
2D. Is the organization exempt from state income tax?
Yes
No
2E. Is the organization exempt from federal income taxes? If yes, attach a copy of your IRS determination letter. If the application is pending, attach a copy of
the first page of the application.
Yes - Provide status: 501(c)(
)
No
Application pending
3. Method(s) of soliciting the organization anticipates using (check all that apply to your organization)
Direct mail
Grant writing
Local television
Telemarketing
Magazines or periodicals
Personal contact
Radio
Show or concert
Newspaper
Membership enrollment
Vending business
National television
Other - Describe:
4. Period of time during which solicitation is to be conducted
5. General purposes for which organized
6. General purposes for which contributions to be solicited will be used
SFN 11300 (07-2016)
Page 2 of 4
7A. Name of person in charge of organization's books and records in North Dakota
Telephone number
7B. Address
City
State
ZIP code
8. Month and day accounting year ends
9. Total contributions the organization received during the last ended accounting year
10. Complete the following for the most recent twelve-month accounting year (attach financial statement or IRS form 990)
REVENUE (Must be completed)
EXPENSES (Must be completed)
$
$
Contributions
Program services
$
$
Trust funds
Solicitation expenses
$
$
Gifts, bequests
Salaries, wages, fringe benefits
$
$
Grants
Rent
$
$
Interest from investments
Accounting services
$
$
Other revenue
Professional fundraisers
TOTAL REVENUE
$
0.00
$
Other expenses
$
TOTAL EXPENSES
$
Excess or deficit
0.00
$
END OF YEAR FUND BALANCE / NET WORTH
Total assets
$
$
Total liabilities
(Assets minus liabilities)
0.00
11. Solicitation conducted by
Voluntary unpaid solicitors
Paid solicitors
Both
12. If solicitation is provided in whole or part by paid solicitors, list the name and address of each professional fundraiser supplying the solicitors and a copy of
the agreement. Attach an additional sheet if necessary. If a contract, written agreement, or statement of any arrangement is made between an applicant and
professional fundraiser/solicitor after a solicitation registration, the applicant agrees to file a copy of such contract or agreement with the Secretary of State.
12A. Name of professional fundraiser
Telephone number
Address
City
State
ZIP code
12B. Name of professional fundraiser
Telephone number
Address
City
State
ZIP code
13. Has the organization or any member thereof been involved in any civil or criminal litigation in the past year?
Yes - Attach a summary statement of the litigation, the outcome, and the parties involved.
No
14. Has the organization been denied the right to solicit contributions, at any time, by any government or any court?
Yes - Attach an explanation.
No
15. Supervisory/guiding/administrative/managing/governing body that adopted the resolution to execute this registration statement
16. Date resolution adopted
Board of directors
Trustees
Managing group
17. Must be signed and certified by an officer:
I, the undersigned, certify that:
• I am a duly elected officer of the applicant organization and have been authorized to prepare and execute this application;
• The board of directors/trustees/managing group have supervised and will continue to supervise the finances of the organization and will continue to
assume responsibility for determining matters of policy;
• The information supplied is true, correct, and complete to the best of my knowledge; and
• If I make a false statement in this registration, I may be subject to criminal penalties.
Printed name
Title
Signature
Date
18. Name of person to contact about this document
Email address
Daytime telephone number
SFN 11300 (07-2016)
Page 4 of 4
CHARITABLE ORGANIZATION REGISTRATION STATEMENT (continued)
9. Provide the total contributions the registrant received during the last ended accounting year.
10. Provide the figures for revenue and expenses for the most recent twelve-month accounting year. These amounts must be completed; the Secretary
of State will not interpret amounts from the attached financial statement or IRS form 990.
11. Check the box to indicate whether solicitors are voluntary, paid, or a combination of both.
12A. If a professional fundraiser is employed, provide the name, address, and phone number of the fundraiser. A fundraiser must file the Professional
Fundraiser Application before this registration can be filed, and is available from the Secretary of States website at sos.nd.gov.
12B. If a second professional fundraiser is employed, provide the name, address, and phone number of the fundraiser. If additional fundraisers are
employed, attach a list.
13. Indicate whether any member of the organization has been involved in any civil or criminal litigation in the past year. If “Yes”, attach an explanation.
14. Indicate whether the organization has been denied the right to solicit contributions in any jurisdiction. If “Yes”, attach an explanation.
15. Check the box that defines the governing body of the organization.
16. Provide the date on which the organization passed a resolution to file the Charitable Organization Registration Statement in North Dakota.
17. The registration must be signed and dated by an authorized officer of the organization that is named in the attached list of names and addresses of all
directors, officers and trustees.
18. Provide the name, email address, daytime telephone number, and extension, if any, of a contact person if this office has any questions or needs
additional information. The email address is not disclosed to the public; this information is privatized in accordance with N.D.C.C., Section
44-04-18.21.
ASSISTANCE: If assistance is required to complete the registration, contact the Secretary of State at (701) 328-3665.
FAX FILING: The document and Credit Card Payment Authorization may be faxed to (701) 328-1690. A faxed filing does not expedite the process of the
document in the office of the Secretary of State.
EMAIL: Email is not a secure utility for the transmission of private information or credit card authorizations. DO NOT EMAIL YOUR DOCUMENT TO THE
SECRETARY OF STATE.
MAILING INSTRUCTIONS: Send documents and filing fees to:
Secretary of State
State of North Dakota
600 E Boulevard Ave Dept 108
Bismarck ND 58505-0500
Telephone: (701) 328-3665
Toll-Free: (800) 352-0867 (option 8)
Fax: (701) 328-1690
Website:
sos.nd.gov
ANNUAL REPORT: A Charitable Organization Annual Report (SF 11302) must be filed with the Secretary of State every year. The annual report is due on
September 1st with the first annual report due the next September 1st following this registration unless registered in July or August; then September 1st of the
subsequent year. Annual report forms are prescribed by the Secretary of State. They are available from the Secretary of States website at sos.nd.gov and are
also mailed to the address of the principal executive office.
WO Number (For Office Use Only):
CREDIT CARD PAYMENT AUTHORIZATION
SECRETARY OF STATE
SFN 51478 (02-2016)
Amount
.
Name
Telephone Number
Address
City
State
ZIP Code
Card Type
Signature (required by credit card companies)
Visa
MasterCard
Discover
American Express
Account Number
CSC Number*
Card Expires (MMYY)
Date
*Three-digit (Visa, MasterCard, or Discover) or four-digit (American Express) security code
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