If applicable:
An audited financial statement conducted according to Generally Accepted Accounting Principles for an organization that has received $500,000 or more in contribution during its fiscal year.
OR
A reviewed or audited financial statement conducted according to Generally Accepted Accounting Principles for an organization which has received $300,000 - $499,999 in contributions during the fiscal year.
HOW TO FILE
Email to: DFICharitableOrgs@wi.gov
Mail to: WDFI/Charitable Orgs PO Box 7879 Madison, WI 53707-7879
Phone: 608-267-1711
Fax: (608) 267-6813
DFI/DCCS/1952I (R 01/20) CO WI SUPPLEMENT TO FINANCIAL REPORT |
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Chapter 202, Wis. Stats. |
STATE OF WISCONSIN |
Division of Corporate and |
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Subchapter II |
Department of Financial Institutions |
Consumer Services |
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E-Mail To: |
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Mail To: |
DFICharitableOrgs@wi.gov |
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PO Box 7879 |
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Madison, WI 53707-7879 |
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Call: (608) 267-1711 |
FORM #1952 - WISCONSIN |
Fax: (608) 267-6813 |
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www.wdfi.org |
SUPPLEMENT TO FINANCIAL |
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REPORT |
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ORGANIZATION INFORMATION - SECTION A |
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1.Name of charitable organization and any trade names or DBA (doing business as) names the organization uses.
2.WI Charitable Organization Number:
3.Federal Employer Identification Number:
4.Provide the name and contact information of the individual the Department should contact about this form:
First Name: |
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Last Name: |
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Street Address: |
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State: |
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Zip Code: |
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Email: |
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5. Did your organization use a professional fund-raiser or fund-raising |
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Yes |
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No |
counsel during the fiscal year in Wisconsin? |
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If YES, provide contact information for each fund-raiser(s), fund raising counsel(s), or person. Attach additional pages, if necessary.
Name: |
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Fund-Raiser: |
Fund-Raising Counsel: |
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Street Address: |
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Does this fund-raiser/fund-raising counsel/person have custody of |
contributions at any time: |
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Yes |
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No |
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DFI/DCCS/1952 (R 01/20) |
CO WI SUPPLEMENT TO FINANCIAL REPORT |
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6.Has any of the information your organization previously submitted to 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.)
If YES, attach an explanation and a copy of the amended document.
FINANCIAL INFORMATION - SECTION B
7.Organization’s Fiscal Year End Date (month, day, and year). Enter the accounting period for the following financial information.
1. Contributions ........................................................................................................................................................
("Contribution" means a grant or pledge of money, credit, property, or other thing of any kind or value, except used clothing or household goods, to a charitable organization or for a charitable purpose. Bequests received directly from the public and indirect public support, such as contributions received through solicitation campaigns conducted by federated fundraising agencies like United Way should be included in this amount. "Contribution" does not include:
Income from bingo or raffles conducted under ch. 563, Wis. Stats.
Government grants
Bona fide fees, dues, or assessments paid by a member of a charitable organization, except that, if initial membership in a charitable organization is conferred solely as consideration for making a grant or pledge of money to the charitable organization in response to a solicitation, that grant or pledge of money is a contribution.)
2. Other Revenues ....................................................................................................................................................
3. Total Revenue (line 1 plus line 2) .........................................................................................................................
a. Expenses Allocated to Program Services .................................................
b. Expenses Allocated to Management and General .....................................
c. Expenses Allocated to Fund-raising .........................................................
d. Expenses Allocated to Payments to Affiliates ..........................................
e. Total Expenses .............................................................................................................................................
5.Excess or Deficit (line 3 minus line 4e) ................................................................................................................
6.Net Assets at Beginning of Year ..........................................................................................................................
7.Other Changes in Net Assets or Fund Balances (See 990, part XI).......................................................................
8.Net Assets at End of Year (Total of lines 5,6 &7) ..................................................................................................
DFI/DCCS/1952 (R 01/20) |
CO WI SUPPLEMENT TO FINANCIAL REPORT |
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ATTACHMENTS
Check the box next to the items that are attached to your annual report. Items A., B., and C. are required. Item D. or E. (or Waiver Application of D. or E.) is required if the contributions received by your organization fall into the described ranges. (Note: If you are submitting this form with your initial application, DO NOT submit the following attachments. Submit the attachments cited in the application form instead).
A.List of all officers, directors, trustees, and principal salaried employees – The list must include each individual’s name, address, and title. Please note that “principal salaried employees” refers to the chief
administrative officers of your organization, but does not include the heads of separate departments or
Rsmaller units within the organization. (You can disregard this item if you are attaching an IRS 990 that
Ealready includes the requested information.)
Q
U B. A list of states that have issued a license, registration, permit, or other formal authorization to the
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organization to solicit contributions. (You can disregard this item if you are attaching an IRS 990 that |
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Ealready includes the requested information.)
D
C H E C K
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C.IRS Form #990, 990EZ, or 990-PF. Do not include Schedule B of the 990.
(Note: If you file an IRS Form 990-N, you cannot use this form. You must complete a Form #1943 or Form #308 instead.)
D. Audited Financial Statements if the organization received contributions in excess of $500,000 during its fiscal year. The financial statements must be prepared in accordance with generally accepted accounting principles and be accompanied by the opinion of an independent certified public accountant.
OR
Apply for Waiver of “D. Audited Financial Statements” if (1.) the organization’s contributions were, during each of the past 3 fiscal years, less than $100,000; and (2.) during the fiscal year for which the waiver is being requested, the organization received one or more contributions from one contributor that exceeded $400,000. Include documentation to support (1.) and (2.).

E. Reviewed Financial Statements if the organization received contributions in excess of $300,000, but not more than $500,000 during its fiscal year. The financial statements must be prepared in accordance with generally accepted accounting principles by an independent certified public accountant. Audited financial statements are also acceptable.
OR
Apply for Waiver of “E. Reviewed Financial Statements” if (1.) the organization’s contributions were, during each of the past 3 fiscal years, less than $100,000; and (2.) during the fiscal year for which the waiver is being requested, the organization received one or more contributions from one contributor that exceeded $200,000. Include documentation to support (1.) and (2.).
DFI/DCCS/1952 (R 01/20) |
CO WI SUPPLEMENT TO FINANCIAL REPORT |
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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.
Name (Print)
Signature of Officer
Date
AND
Name (Print)
Signature of Chief Fiscal Officer
Date
This document can be made available in alternate formats upon request to qualifying individuals with disabilities.
RETURN MATERIALS TO:
Department of Financial Institutions
Division of Corporate and Consumer Services
Mailing Address:
PO Box 7879
Madison, Wisconsin 53707-7879
Or
E-mail:
DFICharitableOrgs@wi.gov
Phone Number: 608-267-1711
Notice: Completion of this form is required under Section 202.12, Wisconsin Statutes. Failure to comply may result in further action by our Department. Personal information you provide may be used for secondary purposes.
DFI/DCCS/1952 (R 01/20) |
CO WI SUPPLEMENT TO FINANCIAL REPORT |
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