West Virginia Secretary of State 
 WEST VIRGINIA UNIFIED REGISTRATION 
                                                                                                          Charities Division 
 STATEMENT SUPPLEMENT
                                                                                                         One Stop Business Center 
 Form URSS-1                                                                                        13 Kanawha Boulevard West 
 Rev. 10/3/2022                                                                                                          Suite 201 
                                                                                                         Charleston, WV 25302 
FILE ONE ORIGINAL                                                                                                               
(Two if you want a filed stamped                                                                          Tel: (304)558-8000 
copy returned to you.)                                                                                    Fax: (304)558-8381 
                                                                                                         Website: www.wvsos.gov 
FILING FEE:NO FEE TO FILE                                                                           Email:charities@wvsos.gov

       **** This supplement must be completed in its entirety, attached to the Unified Registration Statement **** 
                                 and filed with the Secretary of State.

1.  Actual amount of funds received in the West Virginia during the last fiscal reporting year [see §29-19-5(a)(6)]:

$ 

2.  Actual disbursed for program services in West Virginia during the period covered in this report [see §29-19-5(a)(6)]:

$ 

3.  Amount disbursed for program services outside West Virginia during the same period :

$ 

Explain:

4.  How much did the organization receive from government grants or private foundations during last year?

$