Form CO-2

CHARITABLE ORGANIZATION

─ FINANCIAL INFORMATION FORM ─

JIM RYAN

ATTORNEY GENERAL

PLEASE TYPE OR PRINT IN INK. Organizations that have been in operation less than one (1) year are required to complete this form, in compliance with the "Charitable Organization Registration Statement" Form CO-1 Line 20, and file each form with the Attorney General's Office, Charitable Trust and Solicitations Bureau, 100 West Randolph Street,  Chicago, Illinois 60601.

1.

Name, address and telephone number of the organization:

2.

The books and records are located at the following address and telephone number:

3.

Are the gross receipts for the current calendar/fiscal year expected to exceed $10,000.00?

Yes

No

4.

Please provide the following financial information:

From inception

thru

Month/Day/Year

Month/Day/Year

GROSS RECEIPTS TO DATE

ASSETS

Contributions, Gifts & Grants

$

Cash

$

Program Service Revenue

Accounts Receivable

Dues

Other Receivables

Interest & Dividends

Inventory

Rents

Investments

Fund Raising Events

Land, Buildings, Equip.

Other Revenue

Other Assets

TOTAL

$

TOTAL

$

(IN LIEU OF THE ABOVE FINANCIAL INFORMATION, A CURRENT TREASURERS REPORT MAY BE SUBSTITUTED, PROVIDED THAT IT PROVIDES SUBSTANTIALLY THE SAME INFORMATION)

CERTIFICATION

NOTE:

At least two different persons, familiar with the financial affairs of the organization, are required to sign.  These parties should be the President and the Chief Financial Officer, other authorized Officer or two Trustees.

Name and Title

Date Signed

Address

Name and Title

Date Signed

Address

Subscribed and sworn by me this

day of

, 19

A.D.

Notary Public: