Fillable Section 1. Balance Sheet Concise Statement of Financial (North Carolina Secretary of State)

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Section 1. Balance Sheet Concise Statement of Financial (North Carolina Secretary of State)

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North Carolina Department of the Secretary of State
Charitable Solicitation Licensing Division
Annual Financial Report Form
for charitable or sponsor organizations
CSL Contact Information:
Agency Internet Site: www.sosnc.gov Electronic Mail: csl@sosnc.gov
Telephone: (919) 814-5400 - Toll free for NC residents: 1-888-830-4989
Facsimile: (919) 807-2220
Mailing Address: P.O. Box 29622, Raleigh, NC 27626-0622
Annual Financial Report Form
Form Revision:September 24, 2020
Effective Date: July 24, 2012
Page 1 of 3
1. Organization Name:
2. For Fiscal Year Ending:
Section 1. Balance Sheet – Concise Statement of Financial Position
A. Assets and liabilities:
Amount
3. Unrestricted Assets:
4. Restricted Assets:
5. Fixed Assets:
6. Total Current Assets:
7. Total Current Liabilities:
8. Total Net Assets:
B. Fund balance:
9. Unrestricted net assets at beginning of fiscal year:
10. Unrestricted net assets at end of fiscal year:
11. Total Change in unrestricted net assets:
Sections 2 and 3: Statement of Activities for Reporting Period
Section 2. Support and revenues:
Amount
12. Government grants and contracts:
13. §131F-2(18) qualifying organization grants:
14. §131F-2(5) qualifying bona fide membership fees
15. Program service revenues not exceeding service or good fair market value:
16. Program service revenues over and above service or good fair market value:
17. Corporate or business grants:
18. Contributions designated or received through third party channels (e.g., via
parent group, federated fundraising group):
19. §131F-2(5) non-qualifying donation-based membership fees:
20. Fair market value of “in-kind” contributions and forbearances received:
21. Restricted direct contributions (e.g., endowment giving, charitable gift
annuities, unrealized bequests):
22. Unrestricted direct contributions:
23. Total G.S. §131F-2(5) “contributions” (add items 16 through 22 and enter
total here):
24. Total Support and Revenue (add items 12 through 22 and enter total here):
North Carolina Department of the Secretary of State
Charitable Solicitation Licensing
Annual Financial Report Form
for charitable or sponsor organizations
CSL Contact Information:
Agency Internet Site: www.sosnc.gov Electronic Mail: csl@sosnc.gov
Telephone: (919) 814-5400 - Toll free for NC residents: 1-888-830-4989
Facsimile: (919) 807-2220
Mailing Address: P.O. Box 29622, Raleigh, NC 27626-0622
Annual Financial Report Form
Form Revision: September 24, 2020
Effective Date: July 24, 2012
Page 2 of 3
Section 3. Functional Expense Statement:
(A) TOTAL
(B) Program
Services
(C) Management
and General
(D) Fund raising
Total:
Program Services:
Management and
General:
Fundraising:
North Carolina Department of the Secretary of State
Charitable Solicitation Licensing
Annual Financial Report Form
for charitable or sponsor organizations
CSL Contact Information:
Agency Internet Site: www.sosnc.gov Electronic Mail: csl@sosnc.gov
Telephone: (919) 814-5400 - Toll free for NC residents: 1-888-830-4989
Facsimile: (919) 807-2220
Mailing Address: P.O. Box 29622, Raleigh, NC 27626-0622
Annual Financial Report Form
Form Revision: September 24,2020
Effective Date: July 24, 2012
Page 3 of 3
Joint cost allocations:
48. Are any joint costs from a combined educational campaign and fundraising
solicitation reported in the expense totals for Section 3 (B) Program Services?
YES
NO
If the answer to item 48 is “No”, skip items 49 through 52 and proceed to item 53. If
the answer to item 48 is “Yes”, answer items 49 through 52:
Amount
49. Aggregate (total) amount of joint costs:
50. Amount allocated to Program Services:
51. Amount allocated to Management and General:
52. Amount allocated to Fundraising:
Optional Attachments:
53. You may submit additional explanatory or descriptive information as attachments.
Please check “Yes” here if attaching additional information:
YES
NO
54. FINANCIAL REPORT CERTIFICATION – MUST HAVE THREE (3) SIGNATURES (18 NCAC 11 . 0506 (a))
We, as members of the audit and/or finance committee or as members of the board of directors of the
organization identified above, do hereby certify that the information in this report and any attachments is
true and correct to the best of our individual and collective knowledge.
Name:
Signature
Title:
Name:
Signature
Title:
Name:
Signature
Title
55. Report Completion and Signature Date:
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Section 1. Balance Sheet Concise Statement of Financial (North Carolina Secretary of State)

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Completed 7 February 2021

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