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WARNING: False or misleading statements
OFFICE USE ONLY
Subject to maximum $5,000 penalty. T.C.A. §48-101-514
State of Tennessee
Date Stamped
Department of State
SUMMARY OF FINANCIAL ACTIVITIES
Division of Charitable Solicitations &Gaming
OF A
William R. Snodgrass Tennessee Tower
th
312 Eighth Avenue North, 8
Floor
PROFESSIONAL SOLICITOR
Nashville, TN 37243
FOR A SOLICITATION CAMPAIGN
(615) 741-2555 / (615) 253-5173 (fax)
INSTRUCTIONS:
Professional solicitors must use this form to report financial activities for each individual solicitation campaign conducted for a
charitable organization. This financial report shall be filed with the Secretary of State not more than ninety (90) days after a
solicitation campaign has ended or ninety (90) days after the end of the fiscal year end of any solicitation campaign that lasts
more than one (1) year. If the solicitation campaign is conducted nationally or regionally and is not confined only to this
state, the financial information required to be filed shall be inclusive of the national or regional campaign.
A professional solicitor that receives donations on behalf of a charitable organization, has access to the funds
raised and/or has any authority over a charitable organization’s bank accounts shall file with the report an audit
conducted by an independent certified public accountant.
PSID#:
NAME OF PROFESSIONAL SOLICITOR
: ____________________________________________
Name used during Campaign (if different from above) _______________________________________
NAME OF CHARITABLE ORGANIZATION ON WHOSE BEHALF THE CAMPAIGN WAS
COID#:
CONDUCTED
: ____________________________________________________________________
CAMPAIGN#:
CAMPAIGN PERIOD
:
_____
___
____
Beginning
Ending
______
____
_____
MONTH
DAY
YEAR
MONTH
DAY
YEAR
GROSS REVENUE FROM CAMPAIGN
:
Telemarketing ……………………………………………………$_______________
Direct Mail ………………………………………………………..$_______________
Door-to-Door ..……………………………………………………$_______________
Thrift Store ………………………………………………………. $_______________
Internet Fundraising ……………………………………………..$_______________
Other ………………………………………………………………$_______________
0
TOTAL CAMPAIGN RECEIPTS: ………………………………………………………………..$ ______
__
EXPENDITURES
:
Attach an itemized list of all expenses
TOTAL CAMPAIGN EXPENDITURES…………………………………………………………$ ____________
RECEIPTS PAID TO/RETAINED BY CHARITABLE ORGANIZATION…………………………………….…$ ____________
_________________________________________________________________________________________________
1. Did the Charitable Organization pay for any campaign expenses from the amount of receipts shown to have been
paid to/or retained by them.
Yes ______
Amount $___________________
No _______
2. If there is a “Remainder or Deficit,” attach a detailed explanation. The explanation should include: how the remaining
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 ______
3. Is the audited financial report of the solicitation attached?
Yes _______
No _________
N/A ______