Month/ Year:
Date Mailed:
Prepared By:
Position:
Telephone:
Form 3
(
)
Chapter Annual Report
Fiscal Year Ending September 30, 2013
INSTRUCTIONS:
This information is needed to help obtain necessary funding and support for SCORE. Your compliance is required.
Send a copy of the completed form and reconciled bank statements to the SCORE District Director before October 18th.
The District Director will send the Form 3 and attachments to the SCORE Association office.
CHAPTER IDENTIFICATION:
1. Chapter Name:
Chapter:
District:
2. Mailing Address:
3. Telephone:
(
3a. Fax Number:
)
4. Email Address:
(
)
4a. Website / URL:
5. Please attach a separate sheet for all Branch listings with the same information as above, including the name of the branch manager.
CHAPTER ORGANIZATION:
6. Incoming Chair:
7. Vice Chair:
Home Address:
8. Secretary:
City, State, ZIP:
9. Treasurer:
Telephone Number: (
)
Treasurer Email:
Chair Email:
Mail to the SCORE District Director by October 18th
The SCORE District Director will mail to the SCORE Association office by November 1st
SCORE Association
1175 Herndon Parkway, Suite 900
Herndon, VA 20170
Phone: 1-800-634-0245
Form 3 – FY2013 (August, 2013)
Page 1 of 5
Chapter Name:
Chapter:
District:
10.
Does the chapter have operating bylaws?
Were there any significant changes to the bylaws in FY13? If yes, attach a copy.
Yes
Yes
No
No
11.
Does the chapter establish an annual business plan, budget and goals?
Yes
No
12.
Does the chapter engage in any activity outside the mission of SCORE?
Yes
No
If yes, please attach a detailed description of each activity.
13.
Does the chapter have minimum standards for membership retention?
Yes
No
14.
Does the chapter require all volunteers to complete training within a specified time?
Yes
No
15.
Does each volunteer sign the SCORE Code of Ethics and Conduct annually?
Yes
No
16.
All chapters are required to have a SCORE On-Site-Review biennially.
What was the date of your last review?
17.
Did your chapter sponsor any fundraising events in FY13? (workshops and seminars
are not considered fundraising events)
Yes
No
If yes, attach a schedule listing the four largest special events conducted, as measured by
gross receipts. Also, attach a summary of income and expense for each event.
18.
Did your chapter receive any non-cash or in-kind contributions during FY13?
If yes, provide a list of donors including name, address, date of contribution,
description of property and its Fair Market Value at the date of contribution
(Examples of non-cash contributions would be office rent, supplies, books, products
and professional services from non-members, that the chapter would have paid for
regardless.) In-kind contributions less than $1,000 (individually) or less than
$10,000 (cumulatively) need not be reported in the Form 3.
Yes
No
19.
Does your chapter provide written acknowledgement to donors of individual
contributions of $250 or more. Use Form 15 Acknowledgement of Receipt of Gift
to SCORE. Chapters should retain a copy of each acknowledgement. Do not send
copies with the Form 3.
Yes
No
Does your chapter provide information on the amount of the deductible
contributions to donors of quid pro quo donations in excess of $75? Chapters should
retain a copy. Do not send copies with the Form 3.
Yes
Did the chapter award any grants or other allocations during FY13?
Yes
No
Yes
No
20.
21.
If yes, provide a schedule of the following for each award:
 Recipients institution’s name and address
 Amount awarded
 Relationship of recipient to any person or corporation with an interest in the chapter.
22.
Does the chapter make grants for scholarships, fellowships or student loans?
If yes, provide a statement explaining how the chapter determines those receiving
donations from the chapter, in furtherance of its charitable programs, and
qualification to receive payments.
Form 3 – FY2013 (August, 2013)
NA
No
NA
Page 2 of 5
Chapter Name:
Chapter:
District:
CHAPTER FUNDS:
23 Net Asset Balance as of September 30, 2012 (Line 26)---------------------------------------------------------23a Adjustment (if different than Net Asset Balance above) . Explanation Required. This would occur if
2012 income or expenses were not included in FY12 Form 3.
24 Sources of funds received during FY2013. All Funds Deposited into Chapter Bank Accounts for FY 13
except direct reimbursements to volunteers from SCORE--Include any income deposited in FY14 for FY13.
4100-00
All workshop and seminar fees (gross receipts)(Fundraising should be report in 4600-00)--- $
Dues collected and volunteer contributions ----------------------------------------------------- $
4200-00
4250-00
Sales—Publications, CD’s, Educational Material, etc. to public or other Chapters-------Funds received and accrued by chapter from the association office to reimburse
chapter for clerical expenses –(Include funds received in FY14 for FY13)---------------Funds received and accrued by Chapter from SCORE to reimburse Chapter for Form
14 expenses , (Do not include direct reimbursements to volunteers)-------------------Gifts, grants and other donations. (Attach a list of all donors and amounts. For
donations $5,000 and over, include name, address, date of donation and amount)
Interest on chapter bank accounts including CD’s, Savings, Money Markets, etc. ----
4320-00
4350-00
4400-00
4500-00
$
$
$
$
$
In-Kind Contribution – donated rental space, products and services. Instruction 18, page 2- $
Other income (Detail on a separate sheet)------------------------------------------------------ $
$
24a - Total funds from all sources for FY2013:
25 Use of funds during this year: Include all expenses paid and accrued from Chapter bank accounts:
5100-00
Workshop and seminar expenses (All expenses incurred in conducting reportable
4550-00
4600-00
5200-00
5300-00
events, including the cost of publications, meals, rental of rooms and equipment and
travel to and from workshops-Fundraising expense should be in 8000-00)----------------
$
Travel expenses reimbursed to volunteers by the chapter (Do not include
direct reimbursements to volunteers by SCORE Association)-----------------------Volunteer
training activities (Include fees or stipends paid to trainers, materials and
---
$
chapter meeting expenses)-----------------------------------------------------------------------------5400-00
Office supplies, postage -----------------------------------------------------------------------Office equipment and software (Purchases of any equipment with a life expectancy
5500-00
of one year or more including software)----------------------------------------------------------5600-00
Telephone, fax and internet (Web related expenses are reported in 7200-00)-Clerical support paid by the chapter (Funds paid to employment agencies by
5700-00
chapters for administrative services performed)-----------------------------------------------5800-00
Publications, newsletters and printing-----------------------------------------------------Rent – PAID ONLY – no donated rental space (in-kind), see below -----------------In-Kind Contribution - donated rental space, products and services.
(Must be the same amount as account 4550-00 above)-------------------------------
7000-00
7050-00
$
$
$
$
$
$
$
$
7200-00
Marketing and promotion, Web Design, Support, Subscription & Administrative Fees----
$
7500-00
Donations or grants paid by the Chapter.
Attach an itemized schedule including name of recipient and address. See question 21
Other expenses paid by chapter (Detail on a separate sheet of paper)--------------------
$
8000-00
25a
25b
26
26a
26b
$
Total expenses for FY2013-Be sure to include any expenses paid in FY14 for FY13
Difference Between 24a and 25a
0.00
[Net Income/(Loss)]: ----------------------------------
$
0.00
$
0.00
Net asset balance at September 30, 2013 (lines 23, 23a, 25b)---------------Subtract *Receivables – Income reported above and cash to be received after 9/30/2013 (Include detail)
Add *Payables – Expenses reported above and cash to be paid after 9/30/2013 (Include detail)
$
500.00
$ (
$
27
Net Cash Balance as of September 30, 2013 [Line 26 minus (line26a + line 26b)]
$
28
Reconciled bank statement(s) as of September 30, 2013 (Line 27 and 28 should be the same)
$
)
500.00
Attach a copy of all bank statements (checking, savings, CDs, etc.) as of September 30, 2013
Form 3 – FY2013 (August, 2013)
Page 3 of 5
Chapter Name:
Chapter:
District:
I confirm, to the best of our knowledge and belief, the following representations made to you during your audit.
1.
The Form 3, Chapter Annual Report, is presented in conformity with the accrual basis of accounting and the chapter has
followed the guidelines for the reporting and use of Restricted and Unrestricted funds.
2.
I have no knowledge of fraud or suspected fraud affecting the Chapter involving:
a. Volunteers or employees who have significant roles in the internal control.
b. Others where the fraud could have a material effect on the financial statements.
3.
I acknowledge our responsibility for the design and implementation of programs and controls to provide reasonable assurance
that fraud is prevented and detected.
4.
I have no knowledge of any allegations of fraud or suspected fraud affecting the Chapter received in communications from
volunteers, employees, former employees, former volunteers, or others.
5.
There are no:
a. Violations or possible violations of laws or regulations whose effects should be considered for disclosure in the financial
statements or as a basis for recording a loss contingency.
b. Guarantees, whether written or oral, under which the Chapter is contingently liable.
c. Arrangements with financial institutions involving compensating balances or other arrangements involving restrictions on
cash balances.
d. Lines of credit or similar arrangements.
e. Liens or encumbrances on assets.
f. Leases and material amounts of rental obligations under long-term leases.
g. Amounts held for others under agency and/or split interest agreements.
h. Separate Foundations or activities that have not been reported in the accompanying statement.
6.
I am not aware of any pending or threatened litigation, claims or assessments or unasserted claims or assessments that are
required to be accrued or disclosed in the financial statements, and have not consulted a lawyer concerning litigation, claims or
assessments.
7.
All contributions received by the chapter are accounted for in this annual report for the fiscal year.
8. Based upon my review of the detailed accounting records and knowledge of Chapter activities, I have no knowledge of liabilities
that have not been recorded in the Chapter records or disclosed to the National office for the year ended September 30, 2013
Signatures: I certify the information provided represents a complete and accurate accounting of the chapter’s financial activity for the
past fiscal year, including all receipts and deposits; all expenses and obligations, as well as, all cash and investments including but not
limited to, those held by any and all financial institutions or brokerage houses.
*
Prepared By
Signature and typed name
Date
Outgoing Chair
Signature and typed name
Date
Incoming Chair
Signature and typed name
Date
(
)
Telephone number of preparer
*
Email address of preparer
* Please include in case of questions
Form Reviewed and Approved By
SCORE District Director
Form 3 – FY2013 (August, 2013)
Date
District Number
Page 4 of 5
FORM 3 – In-Kind Contributions
4550-00 and 7050-00
Chapter __________
I have included this insert to list all in-kind contributions for the current fiscal
year.
Fair Market
Value
REPORT ON Lines 4550-00 & 7050-00
Name: __________________
Address: ________________
________________________
Date: _____________
Description:
___________________
$
Name: __________________
Address: ________________
________________________
Date: _____________
Description:
___________________
___________
Name: __________________
Address: _________________
________________________
Date: _____________
Description:
___________________
___________
Name: __________________
Address: ________________
________________________
Date: ______________
Description:
___________________
___________
Name: __________________
Address: ________________
________________________
Date: ______________
Description:
___________________
___________
Name: __________________
Address: ________________
________________________
Date: ______________
Description:
___________________
___________
Total In-Kind Contributions:
Form 3 – FY2013 (August, 2013)
$__________
Page 5 of 5