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COUNTY OF SUFFOLK OFFICE OF THE COMPTROLLER (Suffolk County Government)

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COUNTY OF SUFFOLK
OFFICE OF THE COMPTROLLER
JOHN M. KENNEDY, JR.
Comptroller
APPLICATION FOR REGISTRATION STATEMENT
DATE:
AGENCY:
ADDRESS PHYSICAL
ADDRESS MAILING (If different from above)
PHONE #:
CONTACT:
TITLE:
EMAIL:
REQUIRED DOCUMENTATION:
Articles of Incorporation which documents the purpose of the organization
Annual Notice of New York State Registration for the previous calendar year
501(c) Revenue Code as designated by IRS with Employer Identification Number and
Tax Exempt Status
A written statement documenting the general purpose or purposes for which the solicited
contributions will be used
H. LEE DENNISON BUILDING
•
100 VETERANS MEMORIAL HIGHWAY
•
P.O. BOX 6100
•
HAUPPAUGE, NY 11788-0099
(631) 853-5040 Fax (631) 853-5057
Page 2 of 3
A written statement documenting the names and physical business addresses of the
person or persons in direct charge of conducting the solicitation
A written statement which indicates whether the organization intends to use professional
fund-raisers to solicit funds or contributions from the public. If so, the names and
business addresses of all professional fund-raisers who will be connected with the
solicitation
A list of all organizations or individuals that the organization has donated to and the
amount of each donation during the agency’s prior fiscal year. In addition, a separate
schedule of all Suffolk County veterans and their families assisted by the organization
during the agency’s prior fiscal year
A list of the Agency’s current Board of Directors, including names, addresses and phone
numbers
A written statement indicating the amount of monies collected in the preceding fiscal
year that was expended to assist and support veterans’ programs in Suffolk County and/or
individual veterans and their families in Suffolk County. In addition, a list of
expenditures and donations that comprise the monies expended to assist veterans’
programs and individual veterans and their families
A written statement that the fact of registration will not be used or represented in any way
as an endorsement by the County of Suffolk, the Suffolk County Veterans Services
Agency or the Suffolk County Department of Audit and Control of the solicitation
conducted thereunder
Audited financial statements and/or IRS Form 990s for the organizations prior two (2)
fiscal years. If the previous years’ statements are not finalized, a Profit & Loss Statement
and Statement of Activities for the previous year which clearly identify the organization’s
revenues and program, administrative and fund raising expenses
Complete the following statements detailing the agency’s fin
ancial information for the
previous fiscal year:
(a)
total revenue including donations, contributions, grants, and investments:
(b)
total agency expenses:
(c)
total funds expended to assist veterans and their families:
(d)
amount and percentage of funds raised that were expended to support veterans’
programs in Suffolk County:
Page 3 of 3
(e)
amount of funds that remain undistributed:
(f)
amount of monies paid to professional fundraisers and solicitors:
(g)
total administrative expenses for the agency and the percentage of total administrative
expenses to total agency expenses:
A written statement which distinguishes whether the agency is a national nonprofit, local
nonprofit with a national presence or a local nonprofit veterans organization with respect
to funds raised and expended in Suffolk County.
A copy of the agency’s Certificate of Liability Insurance
A copy of all Suffolk County business licenses and permits to operate in Suffolk County
RETURN THIS FORM WITH YOUR DOCUMENTS.
Please be advised that your application will be reviewed in order of receipt. You will be
contacted if further information is required. Upon conclusion of the application review process,
you will be notified of your organization’s certification outcome.
I certify that the above information submitted to the Suffolk County Department of Audit and
Control is accurate and correct to the best of your knowledge.
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Title
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COUNTY OF SUFFOLK OFFICE OF THE COMPTROLLER (Suffolk County Government)

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Completed 14 February 2021

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