*1.Chapter Information(Required.)

Primary Contact Name

Chapter Name

City

State

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

Chapter Website

Primary Contact Email Address

Primary Contact Phone Number

2.Annual Budget

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3.Federal IRS income tax return (Form 990, Form 990 EZ or Form 990-N)

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4.State/Local income tax return (if applicable)

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5.Bank statement for BEGINNING of fiscal year

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6.Bank statement for END of fiscal year

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7.Statement of Activities

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8.Statement of Financial Position

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9.Annual Audit (if applicable)

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*10.Have you filed your paperwork with Cogency?(Required.)

Yes

No, we are still working on this

No, we need assistance from National to complete this task

Other (please specify)

*11.Have you paid your Cogency 'Statutory Representation Fee'?(Required.)

Yes

No

Other (please specify)