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Charitable Activities Section
Form You can now file reports and
CT-12 Oregon Department of Justice pay by credit card using our
For Oregon Charities online form at
For Accounting Periods Beginning in: 100 SW Market Street VOICE (971) 673-1880
Portland, OR 97201-5702 TTY (800) 735-2900 https://justice.oregon.gov/
Email: charitable@doj.state.or.us FAX (971) 673-1882 paymentportal/Account/Login
Website: https://www.doj.state.or.us
2021 Line-by-line instructions for completing the annual
report form can be found on our website.
Section I. General Information
1. Cross Through Incorrect Items and Correct Here:
(See instructions for change of name or accounting period.)
Registration #:
Organization Name:
Address:
City, State, Zip:
Phone: Fax: Amended
Email: Report?
Period Beginning: / / Period Ending: / /
2. Did a certified public accountant audit your financial records? - If yes, attach a copy of the auditor’s report, financial statements,
accompanying notes, schedules, or other documents supplementing the report or financial statements. Yes No
3. Is the organization a party to a contract with a fundraising firm that relates to solicitations in Oregon? If yes, check the type of
solicitations; in-person; direct mail; advertising; vending machine; telephone; or other solicitations. Yes No
If yes, also write the name of the fundraising firm(s) here: __________________________________________ (If you checked
“other solicitations”, attach an explanation.)
4. Has the organization or any of its officers, directors, trustees, or key employees ever signed a voluntary agreement with any
government agency or been a party to legal action in any court or administrative agency regarding charitable solicitation,
administration, management, or fiduciary practices? If yes, attach explanation of each such agreement or action. See Yes No
instructions.
5. During this reporting period, did the organization amend its articles of incorporation, bylaws, or trust documents, OR did the
organization receive a determination or revocation letter from the Internal Revenue Service relating to its tax-exempt status? If Yes No
yes, attach a copy of the amended document or letter.
6. Is the organization ceasing operations and is this the final report? (If yes, see instructions on how to close your registration.) Yes No
7. Provide contact information for the person responsible for retaining the organization’s records.
Name Position Phone Mailing Address & Email Address
8. List of Officers, Directors, Trustees and Key Employees – List each person who held one of these positions at any time during the year even if they did
not receive compensation. Attach additional sheets if necessary. If an attached IRS form includes substantially the same compensation information,
the phrase “See IRS Form” may be entered in lieu of completing this section. (Oregon law requires a minimum of three directors for nonprofit
public benefit corporations.)
(A) Name, mailing address, daytime phone number (B) Title & (C)
and email address average weekly Compensation
hours devoted to (enter $0 if
position position unpaid)
Name:
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Address:
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Address:
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Phone: (_ _ _)_ _ _ _ _ _ _ _ Email:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Name:
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Address:
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Form Continued on Reverse Side
