New Jersey Office of the Attorney General
                                                                                                                  Division of Consumer Affairs
                                                                                                                  Office of Consumer Protection
                                                                                                                  Charities Registration Section                                                                 
45021                                                                  124 Halseyth                                                                                                                                                                                                       Street, 7  Floor, P.O. Box 
                                                                                                                    Newark, NJ  07101
                                                                                                                     (973) 504-6215

                                                                                                                    Form CRI-200
                                   Short-Form Registration/Verification Statement
                                                                                                                    (Revised April 2008)
                                                                               All questions must be answered.

         Charitable organizations, domiciled or doing business in the State of New Jersey, which receive gross contributions of $25,000 or less 
         per year, are required to submit an initial registration and to renew registration annually. In both circumstances this form may be used. In 
         the event an organization receives gross contributions of less than $10,000 per year and does not compensate anyone to solicit or perform 
         fund-raising activities on its behalf, the organization is exempt from registration, but may still choose to register. The registration fee for 
         charities with gross contributions between $0 and $25,000 is $30, whether the fee is for an initial or renewal registration. Payment is to 
         be made by check or money order, made payable to the “New Jersey Division of Consumer Affairs,” and is due at the time of submission 
         of the form.
          
           1a.  This statement is an     £ Initial       Renewal£                                                Registration   (check one only.)

           1b.  This statement contains the facts and financial information for the fiscal year ending:     _____/ _____/ ________   
                                                                                                                                                                 month           day                   year
           2.   Federal ID Number (EIN) __________________     2a. N.J. Charities Registration Number: CH- _________________________
                                                                                                                                                                                                            (Leave blank ONLY if this is an initial registration.)  
         	 3.     Full legal name of the registering organization:  ______________________________________________________________
                  In care of: (if necessary, otherwise leave this line blank) __________________________________________________________ 
          
           4.   Mailing Address: ____________________________________________________________________  £  Change of Address
                                                                     Street Address                                                               City                                      State                                      ZIP Code 
          NOTE: If “ in care of,” a postal, private or rural delivery mail box number is used, the street address of the charity must be given below.  

           5.     The principal street address of the registering organization________________________________________________________
                  £	Same as Mailing Address                                                                                                  Street Address                                      City                            State                            ZIP Code  

          6.      Does the organization have any offices in New Jersey in addition to the one listed above?                                                                                                                                                   £  Yes      £No       
                  If “Yes,” attach a list giving the street address and telephone number of each office in New Jersey.  

          6a.  If the street address listed above is not where the organization’s official records are kept, or if the organization does not maintain an  
                  office in New Jersey, indicate the name, full address, phone and fax number of the person having custody of the organization’s records,  
                  and to whom correspondence should be addressed.

                   _______________________________________________________________________________________________________
                                  Contact person                                                                                Street address                                        City                                                        State                           ZIP Code
                   ________________________________         ________________________________
                             Telephone number (include area code)                                                                  Fax number (include area code) 

          7.      Organization’s contact information:
                 
                   ________________________________         ________________________________
                                Telephone number (include area code)                                                             Fax number (include area code) 
                  ________________________________         ________________________________
                                                    E-mail address                                                                                           Web site

                                                                       Form CRI-200                  Page 1 of 5

8.    The organization is eligible to file a Short Form Registration because:   
         a)  It  did  not  receive  gross  contributions  in  excess  of  $25,000  in  the  preceding  fiscal  year, AND    all  of  the  organization’s  
             functions, including fund-raising, are conducted by volunteers, members, officers or persons who are not compensated for           
             soliciting contributions.            £ Yes    £No 
    
         b)  It is a fraternal, patriotic, social or alumni organization, historical society or similar organization organized under the provisions  
             of Title 15 of the New Jersey Revised Statutes or Title 15A of the New Jersey Statutes, AND solicitation of contributions is  
             confined to the organization’s membership and performed by members of the organization.                        £  Yes    £No

         c)  It solicits on behalf of a specified individual, and all contributions, without any deductions whatsoever, will be turned over to 
             this beneficiary.             £  Yes    £No   

         d)  It is a local post, camp, chapter or similarly designated element or county unit, of a bona fide veterans’ organization which      
             issues charters to the local elements throughout New Jersey or to any veterans’ organization chartered under federal law or a 
             service foundation of such an organization recognized in the organization’s by-laws.           £ Yes    £No

         e)  It is a private foundation that raised less than $25,000 in public contributions.            £ Yes    £No     
               
Note to question 8:   If after reviewing the answers to questions 8a through 8e, none of the statements can be answered “Yes,” the  
charity is not eligible to use the Short-Form CRI-200 and instead must use the Long-Form Initial Registration  Statement                        
CRI-150-I or the Long-Form Renewal Statement CRI-300R.      

  9.     Have there been changes in the organization’s name, address, Internal Revenue Service (I.R.S.) status, etc. since the date of your 
         last reporting?           £  Yes    £No     
         If “Yes,” please provide the details on a separate sheet of paper, and provide copies of the documentary proof of a name change  
         (example: amendment to incorporation) and/or a copy of the letter of determination from the I.R.S. regarding the tax-exempt-status 
         changes.                

  9a.  Is the organization a chapter or local unit of a parent organization?              £  Yes    £No
         If “Yes,” write in the full name, address and phone number (include the area code) of the parent organization. Please do not use  
         abbreviations. 
         _______________________________________________________________________________________________________
                   
  10.  Purpose for which the organization was created (write in or attach a statement to this registration):  _______________________
          ______________________________________________________________________________________________________

  10a. Does the organization solicit or intend to solicit contributions from the general public in the State of New Jersey (including through  
         the sale of merchandise)?      £  Yes    £No     
         If “Yes,” explain the purpose for which solicited funds are being raised (write in or attach a statement to this registration):        
         _______________________________________________________________________________________________________

  10b. Does the organization solicit funds under any other name(s)?     £  Yes    £No 
         If “Yes,” please attach to this registration a list of all other names used: _________________________________________

  11.  Does the organization register or solicit in other states?         £  Yes    £No
         If “Yes,” please indicate other states here or, if necessary, attach to this registration a list of those states.   __________________

  11a. Has the organization ever been enjoined in any jurisdiction from soliciting contributions or has it been found to have engaged in        
         unlawful practices in the solicitation of contributions or the administration of charitable assets?  £  Yes    £No
         If “Yes,” list the jurisdiction and attach copies all of the relevant documents. _________________________________________

  11b. Has the organization’s charity registration been denied, suspended or revoked by any jurisdiction or state?   £  Yes    £No

  11c. Has the organization voluntarily entered into an assurance of voluntary compliance agreement or any similar order or legal 
         agreement with any jurisdiction, state or federal agency or officer? £  Yes    £No

                                                  Form CRI-200                  Page 2 of 5

  12.  If the answer to 11a, 11b or 11c is “Yes,” please attach to this registration a statement that provides the details of the action,  
       together with the reason(s) for that denial, suspension, revocation, injunction, compliance agreement etc., including the state or  
       jurisdiction involved, the dates and full copies of all related documents.      
       Indicate the attachment of documents to this Registration/Verification Statement by checking this box:     £

  13.  Is the organization currently I.R.S. tax-exempt?   £  Yes    £No    
       If “Yes,” under which section of the code?___________________________________________

  14.  Has the organization’s tax-exempt status been revoked, changed, or refused by the I.R.S.?      £  Yes    £ No     
       If “Yes,” please attach to this registration a statement providing an explanation, including all of the facts, dates, and all letters and  
       notices received from the I.R.S.

  15.  Has the organization used an independent paid fund-raiser, fund-raising counsel or commercial co-venturer?    £  Yes    £No          
       If “Yes,” for what purpose(s) are funds being raised? ____________________________________________________________

  15a. If the answer to question 15 is “Yes,” write in or provide a separate listing of the name(s) of all independent paid fund-raiser(s),  
       fund-raising counsel and/or commercial co-venturer(s):__________________________________________________________                    
  
  16.  Provide on a separate sheet of paper the name, title, street address, telephone number and salary of each officer, director and             
       trustee, and the five most-highly compensated employees in the organization. 
       Indicate the attachment of documents to this Registration/Verification Statement by checking this box:      £        

  16a. Has any person listed in the response to question 16 been adjudged liable in any administrative or civil action, or been convicted 
       in a criminal action involving theft, fraud or deceptive business practices?        £  Yes    £No 
       If the response is “Yes,” please provide all of the details on a separate sheet and also attach to this registration a copy of the order,  
       judgment or other document(s) indicating final disposition of the matter. 
    
       Please  note:  For  the  purpose  of  question  16a,  a  plea  of  guilty,  non  vult,  nolo  contendere  or  any  similar  disposition  of  the  
       alleged activity shall be deemed a conviction. A judgment of  liability in an administrative or civil action would include a finding  
       or admission that the individual engaged in an unlawful  practice relating to the solicitation of contributions or the administration  
       of charitable assets.

We	understand	that	this	registration	is	being	issued	at	the	discretion	of	the	Division	of	Consumer	Affairs	and	agree	that	employees	of	the	
Division	may	inspect	the	records	in	the	possession	of	this	organization	in	order	to	ascertain	compliance	with	the	statute	and	all	pertinent	
regulations.	We	also	understand	that	we	may	be	required	to	provide	additional	information	if	requested.		

We hereby certify that the above information and the attached financial schedule(s) and statement(s) are true. We are aware that if any 
of	the	above	statements	are	willfully	false,	we	are	subject	to	punishment.	

Signature____________________________	Name______________________________		Title	______________	Date	____________

Signature____________________________	Name______________________________		Title	______________	Date	____________

              This form must be signed by two (2) authorized officers of the organization, including the chief financial officer.

                                             Form CRI-200                  Page 3 of 5

               CRI-200 Short-Form Registration Verification Financial Statement

                        Note:  If the financial value of a line item = 0, place a zero in the space provided.
                                                             Please report all figures as GROSS, not NET.

	   Full	legal	name	and	street	address	of	the	organization		

	   Full	legal	name:__________________________________________________________________________________________			

	   Fiscal	year-end	being	reported:		_____/_____/_____						Federal ID Number (EIN) __________________  
	   	  	         																																												month											day												year
	   Mailing		address:		
	   _______________________________________________________________________________________________________
	   	  	         Mailing	Address																										 	 P.O.	Box	Number	or	Suite																																								 	 	 City																																																										State																																														ZIP	code

	   Street	address	of	the	registering	organization:	__________________________________________________________________		
	   	  	         	      	                                  	 	 	 	                              	 Street	Address			           													 	 City																																										State																						 	 	ZIP	Code
	   New	Jersey	Charities	Registration	number:		CH	_______________	-00									Telephone	number:	_________________________
		  	  	         	      	                                  	 	 	 	                              	 	 	                         	 	           	 	 	 									(include area code)			

    A.	Revenue		
    			Line	A1.			 Contributions	&	Donations:	Includes	but	is	not	limited	to	individual	and	corporate	contributions,	donations,	legacies,		
       	     	   bequests	and	gross	receipts	from	fundraising:	
    				 			 	   A1a.		Direct	Public	Support	…………………………………........................		                                                          	 __________________
                 A1b.  Indirect Public Support (including donations from other charities) .....                                                 __________________
    				 			 	   A1c.		 Gross	Contributions                   (add lines 1a and 1b) ..........................................                  __________________

    			Line	A2.			 Government	Grants	.......................................…..............................................		                 	 __________________
    		
    			Line	A3.			 Other	Income			
    				 			 	   A3a.		Membership	dues	and	assessments	……………………........................		                                                     	 __________________
    				 			 	   A3b.		Interest	and	dividends	............................................................................		                  	 __________________
    				 			 	   A3c.		Program	service	revenue	………………………………........................		                                                         	 __________________
    				 			 	   A3d.		Gain	from	sale	of	assets	.........................................................................		                   	 __________________
                 A3e.  Other income (please specify on a separate statement): ........................                                          __________________
                 A3f.   Donations from founder(s) of private foundation .................................                                      __________________
    				 			 	   A3g.		Total	other	income..................................................................................		                 	 __________________

    		Line	A4.			 Total	Gross	Revenue (add lines A1c, A2 and A3g)….....................................                                        __________________

	 	 B.	Expenses
		  		Line	B1.	 Program	…………………………………...................	....................................		                                               	 __________________
     Line B2.  Management, office and general expenses………………...............................                                                     __________________
	 	 	Line	B3.	 Fund-raising	expenses……………………………....................	......................		                                                  	 __________________
     Line B4.  Payments to state/national affiliates (if applicable)………………….............                                                       __________________

	 	 	Line	B5.	   Total	Expenses (add lines B1, B2, B3 and B4)………...................................                                             __________________

	 	 C. Excess or Deficit
		  		Line C1.  Excess or deficit for the year-end noted above (subtract line B5 from A4):....                                                  __________________

	 			Please	Note: The amount of Gross Contributions ( line A1c on this form) determines the registration fee which must be paid and the 	
					form	which	should	be	used.	July	2006	revisions	to	the	Charities	Registration	Act	now	require	all	charities	to	pay	a	registration	fee,		
							including	charities	whose	Gross	Contributions	are	less	than	$10,000.		Further	information	for	charity	registrants	may	be	found	on	our		
							Web	site:	http://www.njconsumeraffairs.gov/ocp/charities.htm			

                                                               Form CRI-200                  Page 4 of 5

                                   Registrants who are qualified to file the 
                     Short-Form Registration/Verification Statement CRI-200
                                                 must submit the following: 

(1)          A completed signed Short-Form Registration Statement CRI-200 with all questions answered, including all lists, statements  
             and attachments as may be required by the answers given to the form’s questions.

(2)          A check or money order in the amount of $30, even if gross contributions did not exceed $10,000. Annual renewal registrations  
             are due within six months of the fiscal year-end.   If filing after the due date, please include the $25 late fee due. Checks should 
             be made payable to the “New Jersey Division of Consumer Affairs.”

(3)          Except when submitting an initial registration, the organization’s charities registration number should be written on all checks,  
             forms, attachments, documents etc. being submitted.

(4)          If the charity was required by the Internal Revenue Service to file an IRS-990 for the fiscal year-end being reported, a copy   
             of the I.R.S. 990 (or 990EZ or 990PF etc.) must be submitted along with the Schedule A and all of the statements, attachments,  
             schedules etc. which were originally attached to the copy submitted to the I.R.S. 

(5)          Photocopies of any orders, judgments, agreements or other documents which show the final disposition of any civil or criminal 
             actions brought against the organization or its board members, marked with the related question number and the charities  
             registration number.

(6)         Only initial registrants are required to submit photocopies of the organization’s bylaws, certificate of incorporation and I.R.S.  
             determination letter. However, copies of these documents must be resubmitted each time they are amended.

(7)          Mail the completed registration, enclosures and any attachments to the:     

                                                New	Jersey	Division	of	Consumer	Affairs
                                                Charities	Registration	&	Investigation	Section	
                                                         P.O. Box  45021
                                                         Newark, NJ   07101

 Should  you  have  questions  regarding  charities  registration  in  New  Jersey,  please  visit  our  Web  site  at                      
 http://www.njconsumeraffairs.gov/ocp/charities.htm where registration information, instructions, forms and a fee schedule  
 may be viewed and/or downloaded. After reading through all of the information on our Web site, if you have further questions, 
 please contact the Charities Registration Section at our hotline number (973)-504-6215 during regular business hours. 

                                                Form CRI-200                  Page 5 of 5