Fill - Free fillable STATE OF MINNESOTA NOTICE OF INTENT TO DISSOLVE, (Minnesota Department of Revenue) PDF form

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Mail To:

Minnesota Attorney General’s Office

ATTN: Charities Division

445 Minnesota Street, Suite 1200

St. Paul, MN 55101

STATE OF MINNESOTA

NOTICE OF INTENT TO DISSOLVE,

MERGE, CONVERT, CONSOLIDATE, OR

TRANSFER ASSETS

(Pursuant to Minn. Stat. § 317A.811)

SECTION A: Nonprofit Information

Legal Name of Nonprofit Organization: _________________________________________________________

Nonprofit Organization’s EIN: ________________________________________________________________

Mailing Address Physical Address

______________________________________________

Contact Person

______________________________________________

Street Address

______________________________________________

City, State, and Zip Code

______________________________________________

Phone Number

_______________________________________________

Contact Person

_______________________________________________

Street Address

_______________________________________________

City, State, and Zip Code

_______________________________________________

Phone Number

1. This form is to provide notice that the organization intends to:

Dissolve Merge Consolidate Convert Transfer Assets

2. Describe the organization’s charitable purpose:

__________________________________________________________________________________________

3. Is the organization exempt from taxation under Section 501(c)(3) of the Internal Revenue Code?

Yes No

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4. Is the organization a private foundation under Section 509(a) of the Internal Revenue Code?

Yes No

5. Under which of the following statutes is the nonprofit organized?

Minn. Stat. ch. 317A Minn. Stat. ch. 322C Other (list statute): ______________

SECTION B: Nonprofit’s Assets and Liabilities

6. Provide a list of assets owned or held by the nonprofit organization, as follows:

6a. Identify each bank or other financial institution at which the organization currently maintains an

account(s), and the total balance of all accounts at each such bank and financial institution (attach a list if

more space is needed):

• NOTE: The organization does not need to identify the account numbers for the bank accounts

underlying its response to this question.

Bank Name Total Balance of All Accounts at Bank

6b. List all other types of assets besides money owned or held by the nonprofit organization, as follows

(attach a list if more space is needed):

Type of Assets Dollar Value of Assets

Securities/Stocks/Bonds

Real Property/Land/Buildings

Personal Property/Furniture/Equipment

Other (describe):

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6c. Identify whether the organization intends to convert any of the assets identified above into cash, and if

so, describe the manner in which the assets will be sold. If the organization is not converting any assets

into cash, state “none” (attach a more detailed explanation if more space is needed):

______________________________________________________________________________________

7. List the organization’s restricted assets, if any, and the specific purpose(s) for which the assets were received.

If the organization holds no restricted assets, state “none” (attach a list if more space is needed):

__________________________________________________________________________________________

_____________________________________________________________________________________

8. Describe the debts, obligations, and liabilities, if any, of the organization:

__________________________________________________________________________________________

______________________________________________________________________________________

9. State the anticipated expenses of the transaction for which the organization is providing notice, including any

attorney fees:

__________________________________________________________________________________________

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10. Identify the following information about each person or entity receiving any assets from the organization

(attach a list if more space, or a more detailed explanation, is needed):

Recipient #1

Recipient Name and Address: _____________________________________________________________

Recipient EIN Number: _________________________________________________________________

Assets Recipient is Receiving: _____________________________________________________________

Dollar Value of Assets: __________________________________________________________________

Is Recipient of Assets Exempt Under Section 501(c)(3)?: Yes No

Identify the General Purpose/Mission of the Organization Receiving the Assets: ______________________

____________________________________________________________________________________

Identify Any Terms, Conditions, or Restrictions Imposed on Assets Transferred to Recipient: ____________

____________________________________________________________________________________

Recipient #2