VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO Box 526, Richmond, VA 23218-0526
Phone: 804-786-1343 + FAX: 804-225-2666 + www.vdacs.virginia.gov
OCRP-102 Revised 06/17
REMITTANCE FORM
CHARITABLE ORGANIZATION
FORM 102
YOU MUST USE THIS FORM TO RECEIVE PROPER CREDIT OF YOUR FEE(S)
Virginians for Alternatives to the Death Penalty (VADP)
P.O. Box 12222
Richmond, VA 23241
Organization name:
Address:
54-1664106
Federal Employer Identification Number:
REGISTRATION FEE AMOUNT
Your annual registration, which includes the annual fee payment, is due every year four months and fifteen days from the
end of the organization’s most recently completed fiscal year, unless the organization has requested an extension of either
three months or six months to file.
Initial: First time registrants pay a $100 initial fee. If the organization has prior financial history, the organization is also
required to pay an annual fee. Organizations with no financial history are not required to pay an annual fee.
Late: If your registration has lapsed, you will be required to pay the $100 late fee and the annual registration fee. You will
Annual: See page six of Form 102 for annual registration fee calculations.
Initial Registration Fee ($100): $. (910-02184)
Late Registration Fee ($100): $. (910-02184)
Annual Registration Fee: $ 200 (910-02619)
(See pg. 6 of Form 102)
Total Fees: $ 200
To assist us in tracking your payment, 1203
please enter your Check Number:
MAKE CHECKS PAYABLE TO “TREASURER OF VIRGINIA“
The Code of Virginia authorizes state agencies to assess interest, administrative charges and penalty fees for returned
checks and past-due accounts in accordance with guidelines promulgated by the Department of Accounts.
PLEASE ATTACH COMPLETED REMITTANCE FORM TO FRONT OF REGISTRATION FORM WITH CHECK
ATTACHED AND MAIL TO:
Virginia Department of Agriculture and Consumer Services
P.O. Box 526
Richmond, VA 23218-0526
VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO Box 526, Richmond, VA 23218-0526
Phone: 804-786-1343 + FAX: 804-225-2666 + www.vdacs.virginia.gov
OCRP-102 Revised 06/17
REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION
FORM 102
Please choose the type of registration:
[LJ Initial Registration
[Lv _]| Annual Renewal
Unless otherwise noted, all information provided on this form and attachments must be for the CURRENT fiscal year.
Financial reports (except budgets) will be for the most recently completed fiscal year. Any change in information filed must
be submitted to Office of Charitable and Regulatory Programs (OCRP) within seven (7) days of the change.
All questions MUST be answered. If a question does not apply, then indicate "NO or "N/A". Failure to properly complete this
form or to submit all additional documentation required by any applicable section of the Rules Governing the Solicitation of
Contributions will result in an incomplete registration. Your organization may not solicit in the Commonwealth of Virginia
until itis properly registered.
1. Organization’s primary name:
Virginians for Alternatives to the Death Penalty
2. List any other names under which you may solicit contributions in Virginia:
VADP
3. Required primary address: 2507 Semmes Ave
Richmond VA 23225
City tate Zip Code
“Primary address" means the bona fide physical street address of the organization or sole proprietor. P.O. Boxes will not be accepted. Pursuant
to Section 57-49.2 of the Code of Virginia, if the organization does not maintain an office, use the address of the person having custody of its
financial records.
>
Does the organization maintain any other offices in Virginia?
Yes
No If "Yes," then attach a list of the addresses and telephone numbers for those offices.
“Other offices” will include locations where the organization may administer a program or house administrative functions. “Other offices” will not
include the names and addresses of chapters, branches or affiliates soliciting in Virginia, as provided in response to question 7 of this form
P.O. Box 12222
5. Mailing address if different from primary address above:
Richmond VA 23241
City tate Zip Code
6. Other contact information: (434) 960-7779
Telephone, including area code Fax, including area code
www.vadp.org office@ vadp.org
nternet URL Organization's official e-mail address*
The Official E-mail address entered above will be used for the notifications unless alternate email
preference is indicated here:
REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Revised 06/17
Form 102, Page 2
7. Locations of other chapters, branches, affiliates:
Does the organization have any chapters, branches or affiliates in Virginia? LJ Yes
If “Yes,”
i) Attach a list of the affiliates’ names, addresses and telephone numbers.
ii) Are the income and expenses of these affiliates included in your organization’s financial statement?
Yes [] No
If “Yes,” a joint registration may be issued to the parent organization which would apply to those subordinate
organizations whose finances are reported jointly with the parent organization. Please refer to 2VAC5-610-30 of
the Rules G ig the Soli i for information regarding whether the parent
qualifies to file a lidated
8. Please check one:
Type of organization
v Corporation
Partnership
Other (specify):
9. Date of incorporation or formation: 02/19/1993
10. In what city was the organization legally established? Charlottesville VA
City State
11. Whatis the main purpose of the charitable organization?
To educate, organize, and advocate for alternatives to the death penalty
in Virginia.
12. Name and address of designated agent for receipt of process (service of legal documents) within the Commonwealth of
Virginia. NOTE: If no agentis the shall be d to have i the Secretary of
the Commonwealth.
Name and Company Name
ress
City State Zip Code
13. Organization’s fiscal year:
a) Dates of the CURRENT fiscal year: From: 01/01/2018 To: 12/31/2018
b) Has the organization recently changed its fiscal year? [_]ves
If "Yes," then provide the dates of the “short” fiscal year:
From: To:
14. Is the organization exempt under the Internal Revenue Code?
REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Revised 06/17
Form 102, Page 3
15. Key personnel:
a) Full name and title of the individuals having signatory power over the organization’s funds:
MichaelE. Stone - Executive Director
Virginia Podboy - Board President
b) Full name and title of the individuals who approve the organization’s budget:
Virginia Podboy - Board President
(on behalf of the full board of directors who approve the budget)
c) Has the organization, or any officer, professional fund-raiser or professional solicitor thereof, ever been
convicted of a felony?
| Yes No If “Yes,” then attach a statement providing a description of the pertinent facts.
=
For the CURRENT fiscal year, attach a listing of the ization’s officers, di: , trustees, and
principal salaried executive staff which includes names, addresses, and titles. We will not accept the
listing provided in the IRS Form 990. Note: Your registration will be considered incomplete if the listing does
not include titles. Addresses are not required if the named individuals are to be contacted at the organization's
primary address.
16. (A) Percentage of fundraising expenses and (B) percentage of contributions dedicated to the charitable purpose for
the most recently completed fiscal year:
16(A): Per of fundraising
1) Total amount of contributions received directly from the public: $ 161,769
(found on the IRS Form 990, Part VIII, line 1h (less government grants)) '
2) Total spent on fundraising, including contracts with professional $ 7,505
fund-raising counsel or professional solicitors:
(found on the IRS Form 990, Part IX, Line 25, Column D)
w
Percent of fundraising expenses: 5
(found on this form, OCRP-102, Line 16A(2) divided by Line 16A(1) %
4) For Federated fund-raising organizations ONLY: State the percentage
withheld from a donation designated for a member agency: %
16(B): Please indicated the percentage of contributions received during the most recently
completed fiscal year that was dedicated to the charitable purpose of the charitable 100
organization: %
17. Does the organization intend to solicit contributions from the public directly (including corporate grant proposals,
door- to-door or telephone solicitations, special events, direct mail, etc.)?
No
18. Does the organization intend to have others outside the organization (e.g. volunteers, federated fund-
raising organizations, etc.) conduct solicitations on its behalf?
Yes
REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Revised 06/17
Form 102, Page 4
19. For the current fiscal year, has your organization entered into an agreement or contract with any person(s) to
conduct any aspects (including planning, managing, or carrying out) of a completed, current or upcoming
solicitation?
C] Yes No If “Yes” to question 19, please indicate the arrangement with your agency by
checking below:
x Category | Type of Arrangement
A A bona fide, salaried officer or employee of the charitable organization or its parent organization
B An outside consultant or professional fundraising counsel
c A paid professional solicitor
If in Question 19 either B or C are checked, then please provide the following information:
a) Listthe name and address(es) of the professional fundraising counsel or professional solicitor(s) and note
the date of each contract that was previously submitted to the Commissioner:
b) Attach a copy of the i: 's Current i contract(s) that were not previously submitted
as required by Section 57-54 of the Code ati H
N
S
. Please indicate how the organization will use the contributions received during the CURRENT fiscal year:
Contributions will be used to pay staff salaries, travel, administration,
communications, technology (website & database), and educational programs.
21. Has the organization been authorized by any other state or governmental agency to solicit contributions?
Yes No If "Yes," then name all such agencies. Submit an attachment ifnecessary.
22. Is the organization, or any officer, professional fund-raising counsel, or professional solicitor for the organization
CURRENTLY enjoined by any court or otherwise prohibited from soliciting in any jurisdiction?
| Yes
23. Has any officer, professional fund-raising counsel, or professional solicitor for the organization ever been convicted
in any jurisdiction of embezzlement, larceny or other crimes involving the obtaining of money under false
pretenses, or the misapplication of funds impressed with a trust?
No If "Yes," then attach a copy of the Order that states the reasons and time
period for the injunction or prohibition.
CL] Yes [v] No If "Yes," then attach a copy of the court Order that states the reasons for
the conviction, or a copy of any applicable pardon.
24. Please indicate the type of solicitation activities that your organization may pursue during the current fiscal
year (check all thatapply):
Type of Solicitation
Telephone
Direct mail
Internet
SI STS| Ss
Special events
Door-to-door
Ss
Personal contact
Other (Specify): — Grant proposals
REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Revised 06/17
Form 102, Page 5
25. Except as otherwise provided, all information required to be filed under Chapter 5 of Title 57 of the Code of Virginia
shall become public records in the Office of the Commissioner, and shall be open to the general public for inspection.
You are required by law to supply this information as a prerequisite to the solicitation of charitable contributions. If
you do not provide the required information, you may not solicit in Virginia. Any change in information filed must be
submitted to OCRP within seven (7) days of the change. In order to assist you in determining whether you have
provided the required information, please respond to the following:
i) Are all questions on the form answered?
Yes CL] No If “No,” then the registration will be considered incomplete.
ii) Are all required attachments included (see page 7 for “Checklist of Required Attachments”)?
Yes L] No If “No,” then the registration will be considered incomplete.
26. OATH OR AFFIRMATION.
We, the undersigned chief fiscal officer ‘(chief financial officer, or treasurer) and president (or other
thorized officer, if presi is to sign), duly authorized to act on behalf of the organization
for which this statement i is made, certify that this and including any
have been examined by us and are, to the best of our Miewiedge and belief, true, correct and | complete
pursuant to the laws of the Commonwealth of Virginia.
We affirm and attest that no funds have been or will knowingly be used, directly or indirectly, to benefit or
provide support, in cash or in kind, to terrorists, terrorist organizations, terrorist activities, or the family
members of any terrorist. We understand that no person shall be regi by the C Ith or by any
locality to solicit funds that are intended to benefit or support a family member of any terrorist.
Signature of the chief fiscal officer, chief financial Signature of the president or other authorized officer
officer, or treasurer
Adam L. Northup Michael E. Stone
Printname Printname
Treasurer Executive Director
Title Title
Date Date
*The persons signing this form as chief fiscal officer (chief financial officer/treasurer) and president (or other authorized
officer) must be designated by title on the current fiscal year’s list of officers, directors, trustees, and principal salaried
executive staff. The registration will be returned as incomplete, if the person signing as chief fiscal officer (chief
financial officer/treasurer), by whatever title, is not identifiable on the listing of officers, directors, trustees, and principal
salaried executive staff as the person authorized to act within the capacity and function of chief fiscal officer (see
Section 57-49.D. of the Code of Virginia). The registration will also be returned as incomplete, if the form is not
properly signed. Copies of the form are not allowed.
Section 57-61.1.A. of the Code of Virginia states that "Registrations by charitable organizations, professional
solicitors, and professional fund-raising counsel are effective, if complete, upon receipt by the Commissioner.”
For more information on determining whether your registration is complete, see:
http://www.vdacs.virginia.gov/consumer/pdf/oca- 102registration.pdf.
Rules Governing the Solici of C ibutions: http://www.vdacs.virginia.gov/forms-
Te a PET pdf.
REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Revised 06/17
Form 102, Page 6
SCHEDULE OF REGISTRATION FEES
FEE CRITERIA*
$30 If your gross contributions for the preceding year do not exceed $25,000
$50 If your gross contributions exceed $25,000, but do not exceed $50,000
$100 If your gross contributions exceed $50,000, but do not exceed $100,000
$200 ‘If your gross contributions exceed $100,000, but do not exceed $500,000
$250 ‘If your gross contributions exceed $500,000, but do not exceed one million dollars
$325 If your gross contributions exceed one million dollars
e “Gross contributions” means the total contributions received by the organization from all sources, excluding
government grants (this amount is found on Line E under Computation of Fee Criteria below).
e Organizations with no prior financial history filing an initial registration shall be required to pay an initial fee of
$100.
e Organizations with prior financial history filing an initial registration shall be required to pay an initial fee of $100 in
addition to the applicable annual registration fee.
*Any organization which allows its registration to lapse shall be required to pay a $100 late fee in addition to
the annual registration fee.
*COMPUTATION OF FEE CRITERIA
Due to the diversity in reporting, the following computation should be used as a quide for calculating the required
annual registration fee.
Total contributions, gifts, grants, etc. (IRS Form 990, Part VIII, Line 1h) A $ 161,769
Subtract
e Funds received from federated fundraising organization (FFO)*
(IRS Form 990, Part VIII, Line 1a): B $0
* Government Grants (IRS Form 990, Part VIII, Line 1e) c $0
Total Deductions (add Lines B and C) D $0
GROSS CONTRIBUTIONS (subtract Line D from Line A) E $ 161,769
*“The federated fundraising organization (FFO), as defined in §57-48 of the Code, must register annually with the
Commissioner to qualify for subtraction of funds in the fee computation. Enter the complete name of the FFO below:
Name of FFO:
REGISTRATION STATEMENT FOR A CHARITABLE ORGANIZATION Revised 06/17
Form 102, Page 7
FORM 102 — CHECKLIST OF REQUIRED ATTACHMENTS
ALL Registrants MUST file the following Items:
Remittance form and check, made payable to "Treasurer of Virginia."
Listing of names, titles, and addresses of this year’s officers, directors, trustees, and any principal salaried
executive staff. Titles are req are not req! ired if the named individuals are to be
contacted at the organization's primary address. We will not accept the listing included in the most recently
completed IRS Form 990 since that listing is not for the current year.
Financial report. All organizations with prior financial history, shall file a copy of one of the following:
(1) The most recently completed IRS Form 990, 990-PF, or 990-EZ, with all schedules, as required by the
IRS, except Schedule B, and with all attachments, as filed with the IRS. The form or, if the
form is filed electronically with the IRS, the organization must submit a signed copy of the IRS e-file
signature authorization; or
(2) Certified audited financial statements for the most recently completed fiscal year; or
(3) If the annual income of the organization qualifies the organization to file Form 990-N with the IRS, a
certified treasurer's report for the past fiscal year. Form 990-N is NOT an acceptable financial statement. A
"certified treasurer's report" is an income and expense statement and a balance sheet for the mostrecently
completed fiscal year and include the certification signed by the treasurer, “I hereby certify that, to the best
of myknowledge, that the financial statement above is accurate and correct. I/signed.”
Important Note: If your most recently completed financial report is not ready by the registration due date,
you may request an extension of time to file your registration statement for either 3 or 6 months. The
extension request may be mailed, faxed to our office at 804-225-2666, or emailed to
OCARPUNIT.vdacs@ vdacs.virginia.gov, and will include: 1) the organization’s name, 2) Federal
Identification Number (FEIN), and 3) the extension request length of time, which is either for 3 months or for
a total of 6 months.
If you do not provide the correct financial report by the required/extended due date, you will be assessed a
late fee of $100.
Newly formed organizations: shall file a copy of the board-approved budget of anticipated revenues and
expenses for the CURRENT year. Please notate on the budget the date of board approval.
A list of the addresses and telephone numbers for any branch offices in Virginia, if you answered “yes” to
question 4.
A list of any chapters, branches or affiliates' names, addresses and telephone numbers, if you are a parent
organization as identified by your response to question 7.
Copy of signed contract(s) between your organization and each professional fundraising counsel and / or
professional solicitor, if you answered “yes” to question 19.
Copy of any amendments to your articles of incorporation, not previously filed. If unincorporated, file any
amendments to the governing documents, not previously filed.
Copy of amendments to your by-laws, not previously filed.
IRS determination letter and any subsequent modifications, if the organization is listed with the IRS as tax
exempt, not previously filed. If tax-exemption is pending, the completed IRS application form, as filed
with the IRS.
First-time / Initial filers MUST also file copies of the following Items:
Certificate of incorporation, if the organization is incorporated. If the organizing jurisdiction does not issue a
certificate, the articles must bear a state stamp or seal.
Articles of incorporation, if the organization is incorporated, and any subsequent amendments to those
documents. If unincorporated, file any other governing documents.
Bylaws and any amendments.
OOF Boo00
IRS determination letter and any subsequent modifications, if the organization is listed with the IRS as tax
exempt. If tax-exemption is pending, the completed IRS application form, as filed with the IRS.
CC BY-NC-SA 4.0