West Virginia Secretary of State 
 WEST VIRGINIA UNIFIED REGISTRATION 
                                                                                                           Charities Division 
 STATEMENT SUPPLEMENT
                                                                                                         One Stop Business Center 
 Form URSS-1                                                                                        1615 East Washington Street 
 Rev. 5/30/2018                                                                                          Charleston, WV 25311 
                                                                                                                                
FILE ONE ORIGINAL                                                                                          Tel: (304)558-8000 
(Two if you want a filed stamped                                                                           Fax: (304)558-8381 
copy returned to you.)                                                                                   Website: www.wvsos.gov 
                                                                                                    Email: charities@wvsos.gov
FILING FEE:NO FEE TO FILE

       **** 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?

$