WEST VIRGINIA REGISTRATION STATEMENT OF CHARITABLE ORGANIZATION ee Registration Type: [X) New [] Renewal [1] Final Date 1. Official Name of Organization __United Breast Cancer Research Society, nc. Street Address _325 Pennsylvania Avenue SE, Washington, DC 20003-1110 3. Malling Address 325 Pennsylvania Avenue SE, Washington, DC 20003-1110 4. Phone 951-830-4782 Fax, Email swetschensky@ccke-law.com 5. Principal West Virginia address: ifdifferent from above 6. Designated contact person Stephanie Wetschensky ______— Phone: (816)472-9000, —— Purpose of the organization; —Te-nromote research in areas of benefit to mankind with special _ E cae reference to the healing arts. Name, address and respon- NA sible person of each chapter, branch or affiliate in the State, ifany: 9. Are the above chapters, branches or affiliates in- Check one: Up cluded in parent organization's registration? LL 40. Listall names under which applicant intends to solicit if different from official name, ifany: ‘11, State the purposes forwhich the con- _T2.promote research in areas of benefit to mankind with tributions to be solicited willbe used: Peels reference to the Realing arts. 42. Place and date the organization was Delaware samarzo10 legally established: eee Unincorporated 43. The form of the organization (check [&] Corporation [] Foundation C1 association or complete as applicable) OTrust (Other 14a, Has the organization been determined to Xf Yes Type of IRS classification: 501(c)3. be tax-exempt by the Internal Revenue Service? 1 No FORM CHR-1 Issued by the Secretary of State, State Capitol, Charleston, WV. 25305 Revised 114b. Has this exemption been denied, [] Yes _ Ifyes, attach copy of letter of decision. revoked or modified atanytime? 7) Ng 414c. Please check one or more methods of solicitation the organization anticipates using: (J Telephone Appeals OG Door to Door Solicitation [x] Other e-mail, and personal , solicitations, foundation CO Grant writing C1 Combined Appeals earn couonelionn® {J Direct mail [Auction donations from website. (1) Special Events C1 Bingo/Rafle RENEE 45. Names and addresses of all officers, direc- See attachment "List of Officers and Directors” _ tors, trustees and the principal salaried ex- ecutive staff: [All charitable organizations must appoint an independent governing board to oversee expenditures, policies, progress and purposes.] Leone ee eel 46. Name and address of professional fund- WA raising counsel andior solicitor used for fund- raising activities in West Virginia Are current contracts with professional fund-raising counsel D Yes CINo and solictors on file with the Office of the Secretary of State as required by West Virginia law? b. Has the professional fund-raising counsel or professional O Yes CNo solicitor registered and filed a bond with the Office of the Secretary of State as required by West Virginia Law? c. Give the location of any telephone facili- 3 Y oan rea RI ties to be used in solicitation: ‘ ow (Sate) iy d, Give the location and address of any mailing facility to be used in the solicitation of funds: [SSE ASE an BOX Rab] oH Sate) Cay — FORM CHR-1 Issued by the Secretary of Stat, State Capitol, Charleston, WV 25305 Revised 10817. Is the organization authorized to solicit by any other state? (X] Yes 1 No Ifyes, please list four other states: 4, Seeattachment "List of States, | ‘Counties ana Ces where — 2, Registered” 3. 4. 48. Has the organization ever been enjoined by any court, or otherwise []_Yes [X] No prevented by any governmental body, from soliciting contributions in any state? (Ifyes, explain in detail on separate sheet) 19. Givenamesand a, Custodian of Seo attachment "Responsible for Custody of Records” _ addresses for the financial records: chief person responsible for = : “ See attachment "Responsible for Custody of Funds’ thefollowing _b, Custodian of . duties: contributions: See attachment "Responsible for Distribution of Funds” . Person(s) making final distribution: 20, Amount proposed to be raised in West Virginia (estimate) s 100,00 21. Actual amount of funds raised in West Virginia last fiscal year 0 22, Amount disbursed for program services in West Virginia during s_Y the petod covered by this report: (Please estimate fle blank, @ = (C) ‘$0 will be entered) ——E 23. Amount disbursed for program services outside West Virginia during the same period: $ | 24, The license number of the raffle, bingo or other state permit used for fund-raising if any: WA 25. Computation of Fund-Raising Percentage : 0.00 _ 0.00 : ° a Fund-Raising Expenses income Derived From Fund Raising Percentage 26. How much did organization receive fromgovernmentgrants $900. or private foundations during last year? —— eee ee Revised 108 FORM CHR: Issued by the Sesretary of Site, State Capitol, Chaleston, WW. 2530S