Dissolution Questionnaire

Point of Contact Information

Please provide the information for the person who we will be primarily contacting for the completion of this service.

Contact Name*

First Last

Phone*

Email*

Organization Information

Organization Name*

Organization Address

Street Address Address Line 2 City State ZIP Code

Organization Email

Organization Phone

Organization Website

Application Information

What is the name of the person will retain the books and records of the organization?*

First Last

What is the address of the person will retain the books and records of the organization?*

Street Address Address Line 2 City State ZIP Code

EIN Number*

What is the reason for your dissolution?*

What is your IRS tax exemption status?

The organization has received 501(c)(3) tax exempt status.
The organization has wound up its affairs and has no assets.
The organization has assets (other than a nominal amount for final expenses).

Please upload 990, 990-EZ, or 990-PF forms for the last three periods (Form 990-N is not acceptable).

Drop files here or

Max. file size: 2 MB, Max. files: 6.

Please upload audited financial statements for the last 3 years, if prepared.

Drop files here or

Max. file size: 2 MB, Max. files: 6.

Please upload financial reports through the most recent fiscal period.

Drop files here or

Max. file size: 2 MB, Max. files: 6.

By what date does the organization expect to wind up its affairs?*

Provide a current listing of the organization's assets and liabilities.*

Asset Name/Title	Estimated Value

Explain the organization's plan as to the disposition of these assets. If the articles of incorporation include a dissolution clause, is the plan in accordance with it?*

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Comments

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Point of Contact Information

Organization Information

Application Information

Terms and Conditions

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