Fund Raising Counsel Registration Statement Form - State Of Connecticut Department Of Consumer Protection
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1STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
FUND RAISING COUNSEL REGISTRATION STATEMENT
FORM CPC-56 REV. OCT 10
TELEPHONE (860) 713-6170
Email: CTCHARITYHELP@CT.GOV
FUND RAISING COUNSEL REGISTRATION STATEMENT
PLEASE READ INSTRUCTIONS BELOW BEFORE COMPLETING THIS FORM
1. Is the fund raising counsel now or has the fund raising counsel ever been registered under the
Connecticut Solicitation of Charitable Funds Act?
Yes
No
If yes, state the Connecticut Fund Raising Counsel Registration Number: ________ - ____________
2. Provide the full legal name and mailing address of the fund raising counsel:
Name:
Address:
City, State & Zip Code:
3. Telephone Number (
) _____ - _________
Fax Number (
) _____ - _________
4. Attach a list of the names, residence addresses and titles of all officers, directors and key employees.
5. The fund raising counsel is a (check one):
corporation
partnership
individual
limited liability company
other (describe)_________________________.
The fund raising counsel was organized in the year _____ under the laws of the State of ___________.
6. Is the fund raising counsel registered in other states to provide counseling services?
Yes
No
If yes, attach a list of those states.
7. Has the fund raising counsel’s registration ever been denied, suspended, revoked or enjoined
by any state agency or by any court, or are there such proceedings pending?
Yes
No
If yes, attach a detailed explanation.
8. Provide an Email address where the fund counsel can be contacted (required)
@
_______________________________________________________________________________________
CERTIFICATION
I hereby certify under penalty of false statement that I am authorized to sign this document on behalf
of the fund raising counsel and that the information provided is true and complete to the best of my
knowledge.
Signed:
Date ____/____/____
Print name:
Title
INSTRUCTIONS FOR REGISTERING
Registration is required only of fund raising counsel which at any time have custody or control of contribu-
tions.
Submit completed Fund Raising Counsel Registration Statement (form CPC-56), fully executed Bond Form (form CPC-57), at-
tachments and check in the amount of $120.00 made payable to Treasurer, State of Connecticut to: Public Charities, Department
of Consumer Protection,165 Capitol Avenue, Hartford, Connecticut 06106-1630.
A fund raising counsel is required to have a written contract with each charitable organization for which it provides services. A
copy of the contract must be filed with the Department of Consumer Protection, Public Charities at least fifteen (15) days prior to
the date such services commence.
A fund raising counsel which at any time has custody or control of contributions must account to the charitable organization within
ninety (90) days following the completion of a solicitation campaign lasting less than one year and on each anniversary of the start
of soliciting for campaigns that exceed one year in length.
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