Free ss-6022.indd - Tennessee

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State of Tennessee

WARNING: False or misleading statements Subject to maximum $5,000 penalty. T.C.A. §48-101-514

OFFICE USE ONLY Date Stamped

Department of State

SUMMARY OF FINANCIAL ACTIVITIES

Division of Charitable Solicitations & Gaming OF A PROFESSIONAL William R. Snodgrass Tennessee Tower SOLICITOR FOR A SOLICITATION CAMPAIGN 312 Rosa L. Parks Avenue, 8th Floor Nashville, TN 37243 (615) 741-2555 / (615) 253-5173 (fax)

INSTRUCTIONS: Professional solicitors must use this form to report financial activities for each individual solicitation campaign conducted for a charitable organization. This financial report shall be filed with the Secretary of State not more than ninety (90) days after a solicitation campaign has ended or ninety (90) days after the end of the fiscal year end of any solicitation campaign that lasts more than one (1) year. If the solicitation campaign is conducted nationally or regionally and is not confined only to this state, the financial information required to be filed shall be inclusive of the national or regional campaign. The financial report shall be audited by an independent certified public accountant in accordance with generally accepted auditing standards unless, by contractual agreement with the charitable organization, the professional solicitor does not receive donations on behalf of a charitable organization, does not have access to the funds raised and does not make deposits to and does not have signature authority with, or any other authority over, a charitable organization's bank accounts. NAME OF PROFESSIONAL SOLICITOR: Name used during Campaign (if different from above) NAME OF CHARITABLE ORGANIZATION ON WHOSE BEHALF THE CAMPAIGN WAS CONDUCTED: CAMPAIGN PERIOD: Beginning _____
MONTH

PSID# COID#

___
DAY

____
YEAR

Ending

______
MONTH

___
DAY

____
YEAR

CAMPAIGN#

GROSS REVENUE FROM CAMPAIGN: Telemarketing ............................................................................$ Direct Mail ................................................................................$ Door-to-Door .............................................................................$ Thrift Store ................................................................................$ Internet Fundraising ..................................................................$ Other ..........................................................................................$

TOTAL CAMPAIGN RECEIPTS: ............................................................... $
EXPENDITURES: Attach an itemized list of all expenses TOTAL CAMPAIGN EXPENDITURES ........................................................... $ RECEIPTS PAID TO/RETAINED BY CHARITABLE ORGANIZATION ............................. $

1. If there is a "Remainder or Deficit," attach a detailed explanation. The explanation should include: how the re maining funds will be divided; how the debts of the campaign will be settled; and what the responsibility of the charitable organization is regarding campaign payables. Explanation attached N/A 2. Is the audited financial report of the solicitation attached? No Yes N/A

SIGNATURE SECTION
This report must be signed by an authorized official of the professional solicitor and two (2) authorized officials of the charitable organization. I / we certify that the information furnished in this financial report and all continuation sheets is true and correct to the best of my / our knowledge. This form must be signed in the presence of a Notary. Notary Seal Sworn to and Subscribed before me at:

Signature of Authorized Officer of Professional Solicitor

City This day of

State , 200 .

Print Name

Title

Notary Signature My commission expires:

Date

Notary Seal Sworn to and Subscribed before me at:

Signature of Authorized Officer of Charitable Organization

City This day of

State , 200

Print Name

Title

Notary Signature My commission expires:

Date Notary Seal Sworn to and Subscribed before me at:

Signature of Authorized Officer of Charitable Organization

City This day of

State , 200

Print Name

Title

Notary Signature My commission expires:

Date
SS-6022 (rev. 2/09) RDA 1742