ST. LOUIS COUNTY ANNUAL REPORT FORM NON

ST. LOUIS COUNTY
ANNUAL REPORT FORM
NON-PROFIT ORGANIZATION
Date:
________________
Name of Organization:
1)
_
List the CURRENT NAME, ADDRESS, and TELEPHONE NUMBER of the principal place of
business of the non-profit organization:
_______________________________________________________________
_______________________________________________________________
2)
List the TELEPHONE NUMBER and ADDRESS of each location from which the non-profit
organization will solicit funds, either directly or through professional fundraisers:
______________________________________________________________
______________________________________________________________
3)
If the non-profit organization is a corporation, list the NAME, ADDRESS, POSITION, and
TELEPHONE NUMBER of all officers and director of partners of the organization and of its
registered agent, if any:
______________________________________________________________
______________________________________________________________
4)
List the TOTAL, DOLLAR AMOUNT of funds solicited or collected by or for the organization in
the last fiscal year:
_____________________________________________________________
_____________________________________________________________
5)
What percentage of funds solicited and/or collected was directly expended on the cost of
fundraising for and/or was directly allocated to fundraising activities?
_____________________________________________________________
Licensing Division
41 South Central Avenue  Saint Louis, MO 63105  PH 314/615-5107  TTY 314/615-3746
FAX 314/615-5125 web http://www.stlouisco.com
Revised as of Jan 2012
6)
What percentage of funds solicited or collected in the preceding fiscal year was directly
expended for the organization’s non-profit purposes or was expended or donated for other
charitable purpose?
_____________________________________________________________________
7)
Please provide the NAME, ADDRESS, and TELEPHONE NUMBER of all professional
fundraisers who solicited funds on behalf of your organization last year:
___________________________________________________________________
8)
Please provide the NAME, ADDRESS, and TELEPHONE NUMBER of each professional
fundraiser you plan to use in the upcoming fiscal year:
___________________________________________________________________________
VERIFICATION
STATE OF
)
COUNTY OF
)
) ss
, being duly sworn deposes and says, that s/he
has made the foregoing annual report of a non-profit organization, as required by section 804.210
SLCRO; that s/he has read the foregoing report and knows the contents thereof; that s/he is
authorized to make the foregoing report on behalf of the above named organization; and that the
foregoing report is true to his/her own knowledge; and that the foregoing report was made for the
purpose of complying with the requirements of sections 804.170 through 804.240 SLCRO.
___________________________________
SIGNATURE
________________________________
(PRINTED NAME)
_________________________________________
(TITLE OR POSITION WITH ORGANIZATION)
Subscribed and sworn to before me, this
day of
,
_____.
My commission expires__________________
_________________________________________
(NOTARY PUBLIC)
Licensing Division
41 South Central Avenue  Saint Louis, MO 63105  PH 314/615-5107  TTY 314/615-3746
FAX 314/615-5125 web http://www.stlouisco.com
Revised as of Jan 2012