Chapter 202, Wis. Stats.            STATE OF WISCONSIN                  Division of Corporate and 
                                                        Subchapter II             Department of Financial Institutions  Consumer Services,  
                                                                                                                        Charities Section 

                                                                                                                        Mailing Address: 
                                                         E-Mail:                                                        PO Box 7879 
                                              DFICharitableOrgs@dfi.wisconsin.gov 
                                                                                                                        Madison, WI 53707-7879 

                                              Telephone: (608) 267-1711             WEBSITE:  DFI.WI.GOV 
                                                                                    #1943 AFFIDAVIT                     Courier Address: 
                       Please - Do Not Staple   Fax: (608) 267-6813                                                     4822 Madison Yards Way 
                                                                                  (IN LIEU OF FINANCIAL REPORT)
                                                                                                                        North Tower 
                                                                                                                        Madison, WI 53705 

                                                                                  WHO SHOULD FILE 
                                              • A charitable organization registered to solicit contributions in Wisconsin must file one of the
                                                three annual report forms with the Department of Financial Institutions – Division of Corporate
                                                and Consumer Services.

                                              • A charitable organization should use the form 1943 if:

                                                        o The organization received $25,000 or less in contributions during their
                                                          most recently completed fiscal year.
                                                          OR
                                                        o The organization operates solely in the county in which their principal
                                                          office is located and that received less than $50,000 in contributions
                                                          during their most recently completed fiscal year.

                                              • If the organization does not meet the above criteria please use form 1952 or form 308.

                                              • Please refer to the definitions set forth in Wis. Stat.  §202.12 when completing registration and
                                                report forms.

                                                                                    WHEN TO FILE 
                                              • An annual financial report must be filed with the division within 12 months after the
                                                organization’s fiscal year-end.

                                                                                  WHAT TO INCLUDE 
                                                          Form 1943 – Affidavit in Lieu of Annual Financial Report. 

                                                          An attachment for each question on the form 1943 answered “Yes”. 

                                                          A full list of the organization’s board of directors, officers, trustees and any 
                                                          principal salaried employees. Please include the individual’s name, address and 
                                                          title. 
                                                          A list of states that have issued a license, registration, permit or other formal 
                                                          authorization to the organization to solicit contributions. 

                                                                                    HOW TO FILE 
                                              Email to: DFICharitableOrgs@dfi.wisconsin.gov       Mail to: PO Box 7879 Madison, WI 53707-7879 

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                           ORGANIZATION INFORMATION - SECTION A 

1. Name of charitable organization and any trade names or DBA (doing business as) names the
   organization uses.

                                                                        - 800
2. WI Charitable Organization Number:

3. Federal Employer Identification Number:

4. Supply the organization’s website address:

5. Provide the name and contact information of the individual the Department should contact
   about this form:

First Name:                                     Last Name: 

Street:                                         City:                         State: 

Zip Code:          Phone:                       Email: 

6. Did your organization use a professional fundraiser or fundraising     Yes  No 
   counsel during the fiscal year in Wisconsin? 
         If YES, attach contact information for each fundraiser(s), fundraising counsel(s), or person. 

7. Has the organization changed its purpose(s) or program(s)?             Yes  No 
         If YES, attach explanation. 

8. Has any of the information your organization previously submitted to   Yes  No 
   the division changed?
         (i.e. name of the organization, address of the principal office, address of any Wisconsin branch 
         officers, accounting period, articles, by-laws, etc.) 

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         If YES, attach an explanation and a copy of the amended document. 

                                 FINANCIAL INFORMATION - SECTION B 

Enter the accounting period (month, day and year) that the following financial information applies to. 

9. What is the organization’s Fiscal Year End Date:

Read the descriptions of Affidavit 1 and Affidavit 2, below. Check the affidavit(s) that 
pertains to your organization. 

         Affidavit 1: This organization received contributions of less than $25,000 during the 
         reported fiscal year. 

         Affidavit 2: This organization solicited contributions solely in one county and 
         received less than $50,000 in contributions during the reported fiscal year. 

                  Our organization solicits contributions in the following county. (If your 
                  organization solicits in more than one county, your organization does not qualify 
                  for this affidavit.) 

                  Name of County: 

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                                                            CERTIFICATION - SECTION C 
  
 This document  MUST be  signed by the chief fiscal  officer  and another officer.  Two  different  officer 
 signatures required. Completion of this form is required under Section 202.12, Wisconsin Statutes. 
           
          We, the undersigned, state and acknowledge that we are duly constituted officers of this 

          organization, and that, under penalties of perjury, we have reviewed this report, including 

          all attachments, and to the best of our knowledge and belief, they are true, correct and 

          complete in accordance with the laws of the State of Wisconsin applicable to this report. 
  
 Officer 1 information:                                         Officer 2 information: 

  Name (Print)                                                  Name (Print) 

  Signature                                                     Signature 

  Title                                                         Title 

  Date                                                          Date 
 MUST INCLUDE: 
  
  -       A full list of the organization’s board of directors, officers, trustees and any principal 
          salaried employees. Please include the individual’s name, address and title. 
  -       A list of states that have issued a license, registration, permit or other formal 
          authorization to the organization to solicit contributions. 
  -       An attachment for each question on the form #1943 answered “Yes”. 
  
 RETURN APPLICATION MATERIALS TO: 
 
 Department of Financial Institutions 
 Division of Corporate and Consumer Services 
  
 Mailing Address:                                               Street Address:                                      
 PO Box 7879                                                    4822 Madison Yards Way North Tower                   
 Madison, Wisconsin 53707-7879                                  Madison, Wisconsin 53705 
  
 E-Mail: DFICharitableOrgs@dfi.wisconsin.gov                  
 
This form is required under Section 202.12, Wisconsin Statutes.  Refusal to provide this information may result in the denial of this registration 
application.  Personally identifiable information on this form may be matched against tax information, outstanding child and family support 
data and law enforcement agencies.  Failure to complete this application completely and accurately may result in denial or revocation of 
registration, and any other penalties as provided by law.   
 
This document can be made available in alternate formats upon request to qualifying individuals with disabilities. 
  
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