North Carolina Department of the Secretary of State Solicitation license Application Charitable Solicitation Licensing Division Charitable or Sponsor Organization PO Box 29622 REVISED August 30, 2019 Raleigh, NC 27626-0622 .Phone: 919-814-5400 - NC only Toll Free: 1-888-830-4989 Email: clesosncgov Website: if applicant received less than $25,000 in N.C.G.S. contributions in immediate preceding ?scal year and does not compensate any officer, trustee, organizer, incorporator, fundraiser, or solicitor, applicant may be eligible for EXEMPTION and may ?le "Request for Exemption Under 131F?3l3)? and submit supporting documentation. This Form is available at title[ Charities Charities Sponsors and may be ?led in lieu of the application. 1. Check appropriate box: Initial Application El Renewal Application 2. NC. Charitable Solicitation License Number: (renewal applicants only) 3. Legal Name of Applicant Organization: Piedmont Risi_ng. Inc. 4. Principal Street Address: 3117 Popianivood Court, Suite 114, High Of?ce Park 5. City: Ra e_igh State: NC Zip Code: 27604 6. Mailing address (may not be third pariy mgr): 3117 Poplamood Court, Suite 114, High Of?ce Park, Raleigh, NC 27604 7. Telephone number: (919) 410-8415 I 8. Email address (may not be third party ?ler): info@piedmontrisinq.orq 9. Applicant? 5 Website: 10. List all other NC locations: . Street addressies): 3117 Poplarwood Court, Suite 114. High Of?ce Park, Raleigh. NC 27604 is the sole location of the applicant organization. Telephone numberls): MA I i to promote social welfare. 12. Charitable purpose for which solicited contributions will be used Piedmont Rising, which is to educate and engage the public and advocate for public policy issues in order to promote social welfare. 13_ Major program activities of appiicantiPiedmont Rising is focused on educating and engaging the public on issues North Carolinians care about, particularly, issues related to health care. 14. Applicant's Fiscal Year End Date: (month/day) 12/31 15. Has applicant received a federal tax exemption determination letter? Yes No IRS Tax Exemption Code: See Attachment 501(c)(3) or other code included on Tax Exempt Determination letter) If yes, applicant must provide a copy of their Tax Exempt Determination? letter to the Department with this application or upon receipt to obtain a tax exempt license. Once submitted, the Department will keep the applicant?s letter on file. 16. Applicant's State of Establishment: Carolina Applicant?s Date of Establishment: JUIV 8. 2019 For non-NC corporations: Provide either of the following to verify the applicant?s current legal existence: 1. Certi?cate of Existence or Certi?cate of Good Standing from state of incorporation dated no more than six months prior to date of signing of application, gr 2. Actual webpage screenshot found on a publicly accessible regulatory authority website dated no more than thirty (30) days prior to the date the license application was signed that includes the following elements: 0 Exact name of the entity as it appears on the license application; and 0 Language clearly verifying its status as a corporation in good standing in the state of incorporation ?current" or "active"); and 0 Date the information was printed on the face of the document. For non incorporated applicants: Copy of stamped certi?cate of ?doing business as? or "assumed name? filed with local Register of Deeds must be ?led with application. Page 1 of 3 The following items MUST be included with your application package: PLEASE ATTACH 17. List of all names used by applicant in the solicitation of contributions. All names must be legally registered and documentation of legal registration of all names in state where registered must be ?led with application. WA 18. List of all states where applicant is authorized to solicit contributions. 19. List of names and street addresses of directors, of?cers, trustees, and salaried executive personnel for current ?scal year. (The applicant's street address may be used.) See Attachment 20. List of names of individuals or of?cers in charge of any solicitation activities. Casey Wilkinson 21. List of names, street addresses, and telephone numbers of individuals or of?cers who have final responsibility for custody and/or ?nal distribution of contributions.Sarah Gilchrist FrothinghamL3117 Court, Suite 114, High Of?ce Park, Raleigh, NC 27604; (919) 410-8415 22. Name, street address, and telephone number of individual who has custody of applicant's ?nancial records (if applicant does not maintain an of?ce in North Carolina). applicant organization maintains an of?ce in North Carolina. 23. Financial information: Include with the application at least one of the following documents with ?nancial information for the immediate grecedigg ?scal year. Check all documents that are included with this application. IRS Form 990 or 990-EZ (with dated signature ofauthorized of?cial) [3 Audited Financial Statement NC Annual Financial Report Form Note: Schedule A is required with the Form 990 (available at Charities Charities Sponsors) Note: IRS e-postcard (Form 990-N) is not suf?cient to satisfy the financial information requirement. For newly?Eta?lig??a Wit'fi?o'??a'?ci?alhi??r? a proposed budget for the current ?scal year including projected revenues and expenses must be submitted. - See Attachment #3 24. Contract(s) information: Does applicant intend to enter into, presently have, or had within the last 12 month period a contract(s) with any person who quali?es as a fundraising consultant, solicitor, or coventurer? Yes, intend to enter or presently have Yes, had an active contract within the last 12 months No If yes, for EACH applicable Contractual Agreement or active contract within the last 12 months, attach a completed NC Fundraising Disclosure Form. (available at title] Charities Charities Sponsors) 25. Consolidated Application information: Is applicant applying as a parent organization for one or more subordinate organization(s) (chapter, branch, member or af?liate) located in North Carolina? Yes. No. If yes, attach a list of applicant?s subordinate organization(s), include for each subordinate: (1) organization?s full legal name, (2) for non- incorporated applicants, copy of stamped certi?cate of "doing business as" or ?assumed name" ?led with local Register of Deeds), (3) address for each NC location, (4) contact person for each NC location, and (5) telephone number for each NC location. If yes, attach appropriate parent and subordinate organization(s) ?nancial information in accordance with instructions in Question 23. 26. Federated Fundraising Organization information: Is applicant a United Way, United Arts Fund, community chest, or other federation of independent charitable organizations which have voluntarily joined together for the purpose of raising and distributing contributions and where membership does not confer operating authority and control of the individual group organization upon the federated group organization? El Yes. No. If yes, attach a list of applicant?s member agencies that complies with the following requirements: A. For each NC member agency exempt from license requirements, the agency name, why the agency is exempt (a statutory cite is sufficient), and the amount allocated by the applicant to the member agency during the immediate preceding ?scal year. B. For each NC member agency subject to license requirements, provide the agency? 5 charitable solicitation license number assigned by the Department, the agency name, the agency address, the name of the executive in charge of the member agency, the agency telephone number, and the amount allocated by the applicant to the licensed member agency during the immediate preceding ?scal year. 27. Does applicant compensate (in any capacity) any of?cer, trustee, organizer, incorporator, fundraiser or solicitor? Yes. No. 28. Has applicant or any of its of?cers, directors, trustees, or salaried executive personnel been enjoined from soliciting contributions in anyjurisdiction? Yes. No. If Yes, attach an explanatory statement. Page 2 of 3 29. Has applicant or any of its of?cers, directors, trustees, or salaried executive personnel been found to have engaged in unlawful practices in the solicitation of contributions or the administration of charitable assets in any jurisdiction? - Yes. I No. If Yes, attach an explanatory statement. 30. Has applicant had its authority denied, suspended, or revoked by any governmental agency? El Yes. IX) No. If yes, attach an explanatory statement including the reason(s) for each denial, suspension, or revocation. 31. Has applicant entered into any assurance of voluntary compliance or similar agreement in any jurisdiction? Yes. I No. If yes, attach one (1) copy of each agreement. 32. Calculation of License Fee: Amount of N.C.G.S. contributions received in immediate preceding ?scal year: 0-00 CHECK FEE THAT APPLY AND ENTER THE CALCULATED AMOUNT BELOW: [1 If applicant received less than $25,000 and DID NOT compensate (in any capacity) any officer, trustee, organizer, incorporator, fundraiser or solicitor in the immediate preceding fiscal year: Applicant is EXEMPT, and there is no fee If applicant received less than $5,000 and DID compensate (in any capacity) any of?cer, trustee, organizer, or incorporator, fundraiser or solicitor in the immediate preceding fiscal year: A License is required, but no there is no fee If applicant received $5,000 but less than $25,000 and DID compensate (in any capacity) any of?cer, trustee, organizer, incorporator fundraiser or solicitor, in the immediate preceding fiscal year: A License is required, $50.00 If applicant received $25,000 but less than $100,000 in the immediate preceding ?scal year: $50.00 If applicant received $100,000, but less than $200,000 in the immediate preceding ?scal year: $100.00 If applicant received $200,000 or more in the immediate preceding ?scal year: $200.00 Calculated license fee amount: I 0.00 Calculation of Late Fee. $25. 00 per month following expiration of last license or extension calculated on the ?fteenth day of each month past the due date. $0.00 Total fee amount attached to this application: 5 0-00 MAKE CHECK PAYABLE TO: NORTH CAROLINA DEPARTMENT OF THE SECRETARY OF STATE 33. APPLICANT SIGNATURE: To be signed in the presence of a Notary Public who has administered the following oath: I swear or af?rm that I am the Treasurer or Chief Fiscal Officer (CFO) of the applicant charitable or sponsor organization, and that the information furnished in this application and all supplemental forms, reports, documents, and attachments are true and correct to the best of my knowledge under penalty of er uryyg Signature: Signer's Name (Print): Sarah ilch rothingham Signer's Title (Print): Treasurer and Director NOTARIZATION: I In County It? State (IUDLAQ Sworn to and subscribed before me this the day of ?gum in the year of . Notary Public'sSignature: M7 Notary Public's Name (Print): F0 {14% Date Notary Public's Commission Expires: SURE, 1 1013 Please place notary stamp or seal imprint beside or below this line: 5. 34. Third Party Filer Contact Information (optional): QT TA Name: Telephone Number: $0 Ry i i I Email address: . O. Page (300$