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The following items MUST be included with your application package: PLEASE ATTACH
17. List of all names used by applicant in the solicitation of contributions. All names must be legally registered and documentation of
legal registration of all names in state where registered must be filed with application._____________________________________
18. List of all states where applicant is authorized to solicit contributions.________________________________________________
19. List of names and street addresses of directors, officers, trustees, and salaried executive personnel for current fiscal year. (The
applicant’s street address may be used.)__________________________________________________________________________
20. List of names of individuals or officers in charge of any solicitation activities.__________________________________________
21. List of names, street addresses, and telephone numbers of individuals or officers who have final responsibility for custody and/or
final distribution of contributions.________________________________________________________________________________
22. Name, street address, and telephone number of individual who has custody of applicant’s financial records (if applicant does not
maintain an office in North Carolina)._____________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________
23. Financial information: Include with the application at least one of the following documents with financial information for the
immediate preceding fiscal year. Check all documents that are included with this application.
IRS Form 990 or 990-EZ (with dated signature of authorized official) Audited Financial Statement NC Annual Financial Report Form
Note: Schedule A is required with the Form 990 (available at https://sosnc.gov/forms/by_title/_Charities_Charities_Sponsors)
Note: IRS e-postcard (Form 990-N) is not sufficient to satisfy the financial information requirement.
For newly established applicants with no financial history, a proposed budget for the current fiscal year including projected revenues
and expenses must be submitted.
__________________________________________________________________________________________________________________________________________________________________________________________
24. Contract(s) information: Does applicant intend to enter into, presently have, or had within the last 12 month period a contract(s)
with any person who qualifies as a fundraising consultant, solicitor, or coventurer?
Yes, intend to enter or presently have Yes, had an active contract within the last 12 months No
If yes, for EACH applicable Contractual Agreement or active contract within the last 12 months, attach a completed
NC Fundraising Disclosure Form. (available at https://sosnc.gov/forms/by_title/_Charities_Charities_Sponsors)
25. Consolidated Application information: Is applicant applying as a parent organization for one or more subordinate organization(s)
(chapter, branch, member or affiliate) located in North Carolina?
Yes. No.
If yes, attach a list of applicant’s subordinate organization(s), include for each subordinate: (1) organization’s full legal name, (2) for non-
incorporated applicants, copy of stamped certificate of “doing business as” or “assumed name” filed with local Register of Deeds), (3)
address for each NC location, (4) contact person for each NC location, and (5) telephone number for each NC location.
If yes, attach appropriate parent and subordinate organization(s) financial information in accordance with instructions in Question 23.
26. Federated Fundraising Organization information: Is applicant a United Way, United Arts Fund, community chest, or other
federation of independent charitable organizations which have voluntarily joined together for the purpose of raising and distributing
contributions and where membership does not confer operating authority and control of the individual group organization upon the
federated group organization?
Yes. No.
If yes, attach a list of applicant’s member agencies that complies with the following requirements:
A. For each NC member agency exempt from license requirements, the agency name, why the agency is exempt (a statutory
cite is sufficient), and the amount allocated by the applicant to the member agency during the immediate preceding fiscal year.
B. For each NC member agency subject to license requirements, provide the agency’s charitable solicitation license number
assigned by the Department, the agency name, the agency address, the name of the executive in charge of the member
agency, the agency telephone number, and the amount allocated by the applicant to the licensed member agency during the
immediate preceding fiscal year.
27. Does applicant compensate (in any capacity) any officer, trustee, organizer, incorporator, fundraiser or solicitor?
Yes. No.
28. Has applicant or any of its officers, directors, trustees, or salaried executive personnel been enjoined from soliciting contributions in
any jurisdiction? Yes. No. If Yes, attach an explanatory statement.
