Not-for-Profit Client Intake Form

Organization's Legal Name*

Fiscal Year End Date*

Date

Organization's Phone Number*

Please enter a valid phone number.

Organization's Website*

Please enter a valid website.

Has the primary address changed since the last tax return filed?*

YesNo

Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the primary address the same as the mailing address?*

YesNo

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Name*

First NameLast Name

Professional Title*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Briefly describe the organization's mission: (This will be used on the IRS 990 and will be available to the public)*

Does the organization maintain an office or have employees in New York State?
YES NO*

Does the organization have assets in New York State?
Assets may include cash, investments, accounts receivable, inventory, real estate, and the like.
YES NO*

Was the total amount of assets less than $25,000 at the fiscal year end?
YES NO*

Did the organization solicit or receive contributions during the fiscal year from New York State residents, foundations, corporations, or government agencies, etc.?
YES NO*

Were the total contributions less than $25,000?
YES NO*

Does the organization plan to receive more than $25,000 annually in total contributions from New York State residents, foundations, corporations, or government agencies or other entities?
YES NO*

Did your organization use a professional fundraiser or fundraising counsel for fundraising activity in New York State?
An employee or volunteer for a charity is not a professional fundraiser. A professional fundraiser is an individual or company contracted by a charity to manage, conduct or assist a charity in its solicitations and paid by the charity for such work. Typically, a professional fundraiser solicits contributions on a charity's behalf, and may have access to the contributions raised for a charity.
YES NO*

Choose the range that represents the organization's total New York State contributions in this filing's fiscal year.
*

Did the organization receive government grants during this fiscal year?
YES NO*

Please list EACH government grant awarded by a domestic (federal, state or local) agency; interstate or intergovernmental agency; and state or local authorities. Please include any funding from municipalities that include the organization in their standard budgeting (for example, a volunteer ambulance corps).

	Name of Government Agency	Total Amount
Grant Awarded
Grant Awarded
Grant Awarded
Grant Awarded
Grant Awarded

Please provide the following information for each Board Member relating to the organization:*

	First Name	Last Name	Email Address	Role	Average Hours Per Week	Wages Received
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member
Board Member

The NYS CHAR500 must be signed by two indivudals authorized by the Organization. To help us obtain the required e-signatures, please provide the contact information below:

Signatory #1*

First NameLast Name

Email Address*

example@example.com

Title*

Signatory #2*

First NameLast Name

Email Address*

example@example.com

Title*

Questions/Comments/Notes:

The New York State EPTL fee due at filing, is based on the net worth of the organization.
If both net assets and gross receipts were less than $25,000 there is no NYS filing fee.
Otherwise, please reference the table below for what will be paid when we file your CHAR500 return.

Bank Name*

Account Type*

Business CheckingBusiness Savings

Routing Number*

Accounting Number*

What method do you use to maintain your books and records for the company?*

Required Materials:

Access to QuickBooks Online or copy of QuickBooks/other bookkeeping file
The following statements showing the balance at fiscal year end
- Bank Accounts
- Credit Cards
- Loans
- Investment Accounts

Please upload any supporting documents here:

Terms and Conditions*

Do you have a NYS online portal account with the NYS Charities Bureau?*

YESNO

If YES, what is your username and password? This is required to log in and file the CHAR500 annually.

Username: Type a label
Password: Type a label

If NO, please follow these steps below to create a NYS Charities Bureau Account here:

Scroll down to select "Registration"
Scroll down to check the box "I have read the requirements above."
Select "Continue to charities online registration."
Select "Create Account."

Please provide us with your username and password once you have registered.

Username: Type a label
Password: Type a label

Questions/Comments/Notes:

Not-for-Profit Client Intake Form

Annual Questions

CHAR500 Data