Form FS Annual Financial Report Form - Mississippi

Form FS is a Mississippi Secretary of State - issued form also known as the "Annual Financial Report Form".

Download a PDF version of the latest Form FS down below or find it on the Mississippi Secretary of State Forms website.

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FORM FS
MISSISSIPPI SECRETARY OF STATE
ANNUAL FINANCIAL REPORT FORM
____ Initial
____Final Report
____ Renewal
NAME OF ORGANIZATION
MISSISSIPPI REGISTRATION #
___________________________________________________________________________________________________________
CHARITY CONTACT PERSON:
PERSON COMPLETING FORM:
FORM FS must be completed and be in agreement with financial information reported on IRS Form 990 or
the filed financial statement.
FORM COMPLETED USING:
_______ IRS 990
_______ FINANCIAL STATEMENT
FISCAL YEAR END
________________________
1.
RECEIPTS AND INCOME
CONTRIBUTIONS (LIST SEPARATELY FOR EACH PROJECT OR SOURCE)
1.____________________________________________ $__________________
2.____________________________________________ __________________
3.____________________________________________ __________________
4.____________________________________________ __________________
SUBTOTAL CONTRIBUTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . $_________________
OTHER INCOME (MEMBERSHIP DUES, ENDOWMENTS, ETC.)
1.____________________________________________ $_________________
2.____________________________________________ _________________
3.____________________________________________ __________________
SUBTOTAL OTHER INCOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_________________
TOTAL RECEIPTS AND INCOME:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________________
FORM FS
MISSISSIPPI SECRETARY OF STATE
ANNUAL FINANCIAL REPORT FORM
____ Initial
____Final Report
____ Renewal
NAME OF ORGANIZATION
MISSISSIPPI REGISTRATION #
___________________________________________________________________________________________________________
CHARITY CONTACT PERSON:
PERSON COMPLETING FORM:
FORM FS must be completed and be in agreement with financial information reported on IRS Form 990 or
the filed financial statement.
FORM COMPLETED USING:
_______ IRS 990
_______ FINANCIAL STATEMENT
FISCAL YEAR END
________________________
1.
RECEIPTS AND INCOME
CONTRIBUTIONS (LIST SEPARATELY FOR EACH PROJECT OR SOURCE)
1.____________________________________________ $__________________
2.____________________________________________ __________________
3.____________________________________________ __________________
4.____________________________________________ __________________
SUBTOTAL CONTRIBUTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . $_________________
OTHER INCOME (MEMBERSHIP DUES, ENDOWMENTS, ETC.)
1.____________________________________________ $_________________
2.____________________________________________ _________________
3.____________________________________________ __________________
SUBTOTAL OTHER INCOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_________________
TOTAL RECEIPTS AND INCOME:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________________
2.
EXPENSES –
1.
PROGRAM SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$_____________________
ITEMIZE BY CATEGORY THE
AMOUNT DISBURSED
FOR EACH MAJOR PURPOSE:
PUBLIC EDUCATION
$__________________
_________________________________ $__________________
_________________________________ $__________________
2. ADMINISTRATION (MANAGEMENT & GENERAL) . . . . . . . .
$_____________________
3. FUNDRAISING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$_____________________
4. PAYMENTS TO AFFILIATES . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$_____________________
5. OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$_____________________
TOTAL EXPENSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$___________________
List joint costs reported in Program Services from a combined educational campaign and fundraising solicitation:
Total Amount before allocation : _______________ Amount allocated to Program Services:
____________________
Amount allocated to Fundraising:
____________________
Amount allocated to Management & General: ____________________
I CERTIFY THAT ALL INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
___________________________________________________________
Sworn to and subscribed before me this the
SIGNATURE OF PRESIDENT OR
DATE
OTHER AUTHORIZED OFFICER
________ day of __________________________, 20____
___________________________________________________________
_______________________________________________
PRINTED OR TYPED NAME AND TITLE
NOTARY PUBLIC
NOTARY SEAL
____________________________________________________________
Sworn to and subscribed before me this the
CHIEF FINANCIAL OFFICER
DATE
_______ day of ___________________________, 20___
____________________________________________________________
PRINTED OR TYPED NAME AND TITLE
________________________________________________
NOTARY PUBLIC
NOTARY SEAL
MISSISSIPPI SECRETARY OF STATE
SUPPLEMENT TO UNIFIED REGISTRATION STATEMENT
ANNUAL FINANCIAL REPORT FORM
INSTRUCTIONS
The Supplement to Unified Registration Statement – Annual Financial Report Form (FORM FS) must be
filed along with the Unified Registration Statement. This form must be completed for the most recently
completed fiscal year end.
FORM FS should be completed using the financial information on either the IRS Form 990 or the financial
statement. (If an extension has been filed with the IRS or an IRS Form 990 is not required to be filed, complete
Form FS using the organization’s financial statements.)
ENTER THE NAME OF ORGANIZATION & MISSISSIPPI REGISTRATION NUMBER.
PROVIDE THE NAME OF THE CONTACT PERSON FOR THE ORGANIZATION AND, IF DIFFERENT,
THE NAME OF THE PERSON COMPLETING THE FORM.
ENTER THE FISCAL YEAR END THE REPORT COVERS.
1) IF COMPLETING FORM FS USING THE IRS FORM 990:
RECEIPT AND INCOME (REVENUE) - use Line 1 thru 11
TOTAL RECEIPTS AND INCOME – use Line 12
EXPENSES:
PROGRAMS SERVICES – use Line 13
Break out any funds expended for public education.
ADMINISTRATION (MANAGEMENT & GENERAL) – use Line 14
FUNDRAISING – use Line 15
PAYMENTS TO AFFILIATES – use Line 16
2)
IF COMPLETING FORM FS USING THE FINANCIAL STATEMENT – Statement of Activities
RECEIPTS AND INCOME (REVENUE) - use Support and Revenue
TOTAL RECEIPTS AND INCOME - use Total Support and Revenue
EXPENSES - use Statement of Functional Expenses
PROGRAM SERVICES: Program expense on financial statement – break out any funds
expended for public education.
ADMINISTRATION (MANAGEMENT & GENERAL) – use Management and general
FUNDRAISING – use Fundraising
NOTE: The Other category should not be used for any expense that would be considered program services, management and general
.
or fund-raising
THE
FOLLOWING
INSTRUCTIONS
SET
OUT
THE
SUPPORTING
DOCUMENTS REQUIRED TO BE FILED WITH THE FORM FS.
PLEASE
REVIEW AND SUBMIT THE REQUIRED DOCUMENTATION
.
1) CONTRIBUTIONS OVER $500,000
A financial statement audited by an independent certified public accountant and IRS Form 990 must be
filed along with the Unified Registration Statement and Annual Financial Statement Report if the
organization:
A) Received contributions over $500,000; or
B) Engaged the services of a professional fund-raiser or fund-raising counsel; or if fundraising was
conducted by persons who were paid for performing these services.
The report must be signed by two officers - the president (or other authorized officer) and chief financial
officer and the signatures must be notarized.
2) CONTRIBUTIONS OF $250,000 to $500,000
A financial statement reviewed by an independent certified public accountant and the IRS Form 990 must
be filed with the Unified Registration Statement and Annual Financial Statement Report if the organization:
A) Received contributions of $250,000 to $500,000; and
B) Did not engage the services of a professional fund-raiser /fund-raising counsel and if fundraising was
conducted by persons who were unpaid for performing these services.
The report must be signed by the president or other authorized officer and the signature must be notarized).
3) CONTRIBUTIONS LESS THAN $250,000
A financial statement and the IRS Form 990 or 990EZ must be filed with the Unified Registration Statement
and Annual Financial Statement Report Form if the organization:
A) Received contributions less than $250,000; and
B) Did not engage the services of a professional fund-raiser /fund-raising counsel and if fundraising was
conducted by persons who were unpaid for performing these services.
The report must be signed by the president or other authorized officer and the signature must be notarized.
4) NEW ORGANIZATIONS
The Annual Financial Statement Report must be completed using zeros.
The report must be signed by the president or other authorized officer and the signature must be notarized
A separate Annual Financial Statement Report must be filed for each local division, chapter or affiliate
the Organization has included under its registration (See Miss. Code Ann. Section 79-11-503(7)).
MISSISSIPPI LAW DOES NOT ALLOW FOR AN EXTENSION TO FILE.
Mississippi Secretary of State's Office
Charities Registration
Post Office Box 136
Jackson, Mississippi 39205-0136
(601) 359-1371 or 888-236-6167 (Mississippi only)

Download Form FS Annual Financial Report Form - Mississippi

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