Fillable FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES

Fill Online, Printable, Fillable, Blank FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES

On average this form takes 33 minutes to complete

The FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES form is 7 pages long and contains:

  • 0 signatures
  • 42 check-boxes
  • 112 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FLORIDA DEPARTMENT OF AGRICULTURE AND
CONSUMER SERVICES
NICOLE "NIKKI" FRIED
COMMISSIONER
SMALL CHARITABLE ORGANIZATIONS/SPONSORS
APPLICATION
Chapter 496, Florida Statutes
Rule 5J-7.004, Florida Administrative Code
FDACS-10110 Rev. 01/15
Page I of II
Small Charitable Organizations/Sponsors Filing Instructions
REGISTRATION AND RENEWALS
All charitable organizations and sponsors must register with the Florida Department of Agriculture and Consumer Services
(FDACS) prior to engaging in solicitation activities in Florida, and renew annually thereafter on a form provided by the
department. The department will annually provide a renewal statement to each registrant by mail at least forty-five (45) days
before the renewal date. Charitable organizations and sponsors that meet all of the following requirements are eligible to fill out
the following form in lieu of registration. [s. 496.406(1)(d), F.S.]
The charitable organization or sponsor has less than $25,000 in TOTAL REVENUE (including contributions). The
fundraising activities of the charitable organization or sponsor are carried on by volunteers, members, or officers who are
not compensated and no part of the assets or income of the organization or sponsor inures to the benefit of or is paid to
any officer or member of the charitable organization or sponsor.
The charitable organization or sponsor does not utilize a professional fundraising consultant, professional solicitor, or
commercial co-venturer.
NOTE: If circumstances change and the organization or sponsor no longer satisfies any one of the above criteria
(requirements), the organization or sponsor must register with the department as required by s. 496.405, F.S. within 30 days.
INSTRUCTIONS AND CHECKLIST FOR COMPLETING THE EXEMPTION APPLICATION
If you have any questions or need assistance in completing this application, please contact the department at 1-800-HELP-FLA
(435-7352) or (850) 410-3800.
When filing an application, be certain that the application is completely filled out, that all questions are answered truthfully and
that all the information requested is provided. Please type or print in ink. Additional pages may be attached if additional space
is needed using the same format. Please ensure that all attachments reflect the organization’s name or registration number
and the number of the corresponding question.
Item #1:
Provide the legal name of the organization exactly as it appears in its articles of incorporation or organizational document. If
using a fictitious name (DBA), provide that name also. If the organization solicits under any other names, provide those names
in the spaces listed. Attach additional sheets as necessary using the same format. Note: Corporate, LLC, and Fictitious
Names are verified with the Florida Department of State, Division of Corporations and must match the name exactly as
filed.
Item #2
Provide a street or physical address for the organization. Include the suite, room, or other unit number. Note: In order for
correspondence to be sent directly to an attorney or other third party, you must insert the attorney’s or third party’s
address as the mailing address for the organization.
Item #3
You must provide a primary telephone number, including the area code, for the organization. If the organization does not
maintain a specific location, provide the telephone number of a person who will represent the organization. Also, provide email
address and website if used to provide information to or communicate with the public.
Item #4
Provide the organization’s federal employer identification number. Note: Taxpayers can obtain an EIN immediately by calling
the IRS Business and Specialty Tax Line (1-800-829-4933).
Item #5
Indicate the month and day your accounting or bookkeeping period ends each year.
Item #6
Answer by checking appropriate box.
FDACS-10110 Rev. 01/15
Page II of II
Item #7
List the representatives as directed with complete street addresses and telephone numbers for each. All documents and
attachments submitted with this application are subject to public records review pursuant to Chapter 119, F.S. However,
exemptions apply to certain employees. If you qualify under these exemptions, you can request that certain information be
redacted from the public records available through the department. Exemptions may apply to:
Current or former law enforcement officers and their families;
Current or former judges and their families;
Current or former prosecutors and their families;
Current or former firefighters and their families;
Current or former human resources managers and their families; and
Current or former code enforcement officers and their families.
This is not a comprehensive list. For a complete list, see Section 119.071(4), F.S. If you qualify for one of the public records
exemptions and wish to have your information exempted from public review, please check the appropriate box.
Item #8
Briefly explain the purpose for which your organization was created. It is best to summarize this information in your own words.
Item #9
Briefly explain the purpose for which contributions will be used.
Financial Statement
Indicate by checking the appropriate box on the application which type of financial report you are filing. Only newly established
organizations with no financial history may submit a budget for the current year. The financial statement on page 3 may be
used to prepare a budget. ONLY THE FOLLOWING WILL BE ACCEPTED FOR ALL OTHER ORGANIZATIONS:
IRS form 990 with all attached schedules
IRS form 990-EZ and Schedule O
the financial statement on this form.
We cannot accept the 990-PF, 990-N, E-Postcard or 990-T or any other type of tax return. We cannot accept quarterly
reports or audited reports without the form 990. You may submit these types of financial documents in addition to the required
financial information, but they cannot be a substitute for one of the three acceptable financial reports mentioned above. If
sending multiple financial forms, they must be consolidated prior to submission on the department’s financial report.
Certification Statement
Provide the name and contact information for the person responsible for completing the application.
SEND COMPLETED APPLICATION TO:
FDACS
Solicitation of Contributions
2005 Apalachee Parkway
Tallahassee, FL 32399-6500
IMPORTANT: Every charitable organization or sponsor that is required to register under s. 496.405, F.S., or is exempt
under s. 496.406(1)(d), F.S., shall conspicuously display the following statement on every solicitation, confirmation, receipt,
or reminder of a contribution: “A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE
OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE WITHIN THE STATE.
REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.” The
statement must include a toll-free number and website for the division which can be used to obtain the registration
information. When the solicitation consists of more than one piece, the statement must be displayed prominently in the
solicitation materials. If the solicitation occurs on a website, the statement must be conspicuously displayed on any
webpage that identifies a mailing address where contributions are to be sent, identifies a telephone number to call to
process contributions, or provides for online processing of contributions. The toll-free number of the department is 1-800-
HELP-FLA (435-7352) or (850) 410-3800. The department’s website is www.FDACS.gov.
FDACS-10110 Rev. 01/15
Page 1 of 4
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
SMALL CHARITABLE
ORGANIZATIONS/SPONSORS APPLICATION
Solicitation of Contributions Act
Chapter 496, Florida Statutes
Rule 5J-7.004, Florida Administrative Code
1-800-HELP-FLA (435-7352) • (850) 410-3800
www.FDACS.gov • (850) 410-3804 Fax
All documents and attachments submitted with this application are subject to public review pursuant to Chapter 119, F.S. PLEASE
TYPE OR PRINT. Additional pages may be attached if additional space is needed using the same format. Please ensure that all
attachments reflect the organization’s name or registration number and the number of the corresponding question.
Business Information
New Application
Renewal
CH
DTN
(as listed on the preprinted renewal application)
1.
Legal Name of Organization:
* Fictitious (DBA) Name:
*If you are a Florida organization, all fictitious names must be registered with the Florida Department of State, Division of Corporations. If business is a
corporation then ‘Name’ is the legal name of the business as listed with the Division of Corporations.
Other Names Soliciting As:
2.
Street Address (include APT or SUITE # in all address lines; addresses must match those filed with the Division of Corporations):
City:
State:
Zip Code:
-
Mailing Address (if different from above):
City:
State:
Zip Code:
-
3.
Telephone Number:
Fax Number:
(
)
(
)
-
Email Address for Organization:
Website:
4.
Federal Employer ID Number: [s.119.092, F.S.]
5.
Month/Day fiscal year ends: [s. 496.406(2)(c), F.S.]
/
Month
Day
6.
Has organization been granted tax exempt status by the Internal Revenue Service? [s. 496.406(2)(b), F.S.]
Yes
501(c) __________
(insert number)
No
Pending
NICOLE "NIKKI" FRIED
COMMISSIONER
Return completed application
to:
FDACS
Solicitation of Contributions
2005 Apalachee Parkway
Tallahassee, FL 32399-6500
FDACS-10110 Rev. 01/15
Page 2 of 4
7.
List the names, street addresses, and telephone numbers of the individuals or officers who have final
responsibility for the final distribution of contributions: [s. 496.406(2)(d), F.S.] (attach additional sheets as necessary using the
same format)
NOTE:
Pursuant to s. 496.405(8), F.S., no charitable organization or sponsor, or an officer, director, trustee, or employee thereof,
may not knowingly allow an officer, director, trustee, or employee of the charitable organization or sponsor to solicit contributions on
behalf of such charitable organization or sponsor if such officer, director, trustee, or employee has, in any state, regardless of
adjudication been convicted of, been found guilty of or pled guilty or nolo contendere to, or has been incarcerated within the last 10
years as a result of having previously been convicted of, or been found guilty of, or pled guilty or nolo contendere to, any felony
within the last 10 years or any crime within the last 10 years involving fraud, theft, larceny, embezzlement, fraudulent conversion,
misappropriation of property, or any crime arising from the conduct of a solicitation for a charitable organization or sponsor, or
has been enjoined in any state from violating any law relating to a charitable solicitation. The prohibitions in this subsection also
apply to a misdemeanor in another state which constitutes a disqualifying felony in this state.
Exemptions from public records apply to certain personal information about current or former law enforcement officers, judges,
prosecutors, public defenders, firefighters, code enforcement officers and guardians ad litem and their families. For a complete
list of exemptions, see Section 119.071(4), F.S. If you qualify for one of these exemptions, please do not list your home address
and phone number below.
Name:
Title:
Street Address:
City:
State:
Zip Code:
-
Telephone Number:
(
)
-
Compensated: Yes No
Criminal History: Yes No
Exempt from public records [s. 119.071(4), F.S.] Yes No
Name:
Title:
Street Address:
City:
State:
Zip Code:
-
Telephone Number:
(
)
-
Compensated: Yes No
Criminal History: Yes No
Exempt from public records [s. 119.071(4), F.S.] Yes No
Name:
Title:
Street Address:
City:
State:
Zip Code:
-
Telephone Number:
(
)
-
Compensated: Yes No
Criminal History: Yes No
Exempt from public records [s. 119.071(4), F.S.] Yes No
Name:
Title:
Street Address:
City:
State:
Zip Code:
-
Telephone Number:
(
)
-
Compensated: Yes No
Criminal History: Yes No
Exempt from public records [s. 119.071(4), F.S.] Yes No
FDACS-10110 Rev. 01/15
Page 3 of 4
8.
What is the purpose for which the organization is organized? [s. 496.406(2)(a), F.S.]
9.
What is the purpose for which the contributions will be used? [s. 496.406(2)(b), F.S.]
Financial Statement
FOR ORGANIZATIONS HAVING UNDER $25,000 TOTAL REVENUE FOR FISCAL YEAR ENDING ____/____/_______
CH
DTN
Organization Name
(as issued by the
department)
(as listed on the preprinted
renewal application)
NOTE: In lieu of completing the following financial statement, you may send the IRS form 990 and all attached schedules or the IRS form
990-EZ and Schedule O.
IRS form 990N – ePostcard or IRS 990-PF are NOT acceptable financial statements.
Yes No If newly formed, is this to be considered a budget?
Yes No Is this a consolidated financial statement for chapters, branches and affiliates?
Yes No Did anyone receive pay or benefits (member, officer or employee)?
REVENUE
1. Contributions, gifts, grants, and similar amounts received
1. _______________
2. Government grants (must list sources and amounts)
2. _______________
3. Inventory sales
a. Gross Revenue
3a. _______________
b Less costs
3b. _______________
c. Net Income
3c. _______________
4. Special fundraising events
a. Gross revenue
4a. _______________
b. Less expenses
4b. _______________
c. Net Income
4c. _______________
5. In-kind contributions and services
5. _______________
6. Federated campaigns (must list sources and amounts)
6. _______________
7. Program service revenue
7. _______________
8. Membership dues and assessments
8. _______________
9. Other revenue (must list sources and amounts)
9. _______________
10. TOTAL REVENUE (add lines 1 through 9)
10. _______________
EXPENSES
1. Program services (including payments to affiliates)
1. _______________
2. Management and general
2. _______________
3. Fundraising
3. _______________
4. TOTAL EXPENSES (add lines 1 through 3)
4. _______________
FDACS-10110 Rev. 01/15
Page 4 of 4
Certification
I, _______________________________________________________ am the _____________________________________________ of
Name Title
______________________________________________________________________________________________________________,
Name of Organization or Company
and further state as follows: (please check all that apply)
I certify that I am authorized to complete this application and the information provided is true and accurate. The above
information is provided for the purpose of complying with the provisions of Chapter 496, Florida Statutes.
I certify that the above named charitable organization or sponsor has less than $25,000 in total revenue (including
contributions).
I certify that the fundraising activities of the above named charitable organization or sponsor are carried on by
volunteers, members, or officers who are not compensated and no part of the assets or income of the organization or
sponsor inures to the benefit of or is paid to any officer or member of the above named charitable organization or
sponsor.
I certify that the above named charitable organization or sponsor does not utilize a professional fundraising consultant,
professional solicitor, or commercial co-venturer.
If all of the above are not certified, then FDACS-10100, Solicitation of Contributions Registration Application, Rev. 01/15 must be
completed.
Signature
Print or Type Name
(
)
-
Date
Telephone Number
Email Address
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document