Form Char 014 - Fund Raising Counsel Registration Statement

CHAR 014

FOR OFFICE USE ONLY

STATE of NEW YORK

DATE REC'D.

AMOUNT

Fund Raising Counsel

DEPARTMENT OF LAW

CHARITIES BUREAU

Registration Statement

CASH BK.#

REG. NO.

THE CAPITOL

ALBANY, NY 12224

DATE ACCT.

EXAMINED BY

FOR YEAR ENDING AUGUST 31, 20

INSTRUCTIONS: Please type or print in ink the answers to all applicable items on both sides of this form. (Enter "NA" for any item that is not

applicab le.) In all cases, "the Registrant" shall mean the Fund Raising Counsel named in Item 1A; "Representative of the Firm" shall mean an owner,

principal, partner, director or officer of the Registran t. This fully execu ted statemen t, along with the m andatory fee of $800 (Art. 7-A, Exec. Law),

in the form of a check or money order made payable to the "Department of Law", should be sent to the above address. Please be sure to sign this

statement where indicated and include all attachments, clearly labeled to reference any item requiring additional explanation.

NOTE: The Charities Bureau must be notified in writing within 20 days, if any changes to the information provided in this statement occur during

the period of reg istration (Art. 7-A , Exec. Law ).

1A. FULL, O FFICIAL NAME OF FUND R AISING COUN SEL*

TELEPHONE NUMBER

..................................................................................................................................................................................................

(

).......................................................

PRINCIP AL STRE ET ADDRESS

CITY, STATE, ZIP

...............................................................................................................................................................................................................................................................................

PRINCIPAL NEW YORK STATE ADDRESS, IF NOT THE SAME AS ABOVE

CITY, STATE, ZIP

TELEPHONE NUMBER

..................................................................................................................................................................................................

(

).......................................................

* ITEM #1B ON THE BACKSIDE (BOTTOM) OF THIS FORM MUST BE COMPLETED

A. DOES THE R EGISTRANT OR ANY REPRESE NTATIVE OF THE RE GISTRANT SOLICIT, AS THAT TE RM IS DEFINED IN § 171-A

OF THE EXECUTIVE LAW?.....................................................................................................................................................................................

YES

B. DOES THE REGISTRANT OR ANY REPRESENTATIVE OF THE REGISTRANT HAVE ACCESS TO CONTRIBUTIONS OR OTHER

RECEIPTS FROM SOLICITATIONS?......................................................................................................................................................................

YES

C. DOES THE REGISTRANT OR ANY REPRESENTATIVE OF THE REGISTRANT HAVE AUTHORITY TO PAY EXPENSES

ASSOCIATED WITH A SOLICITATION?...............................................................................................................................................................

YES

D. DOES THE REGISTRANT OR ANY REPRESENTATIVE OF THE REGISTRANT EMPLOY ANY PROFESSIONAL SOLICITORS?.............

YES

3. LIST ALL OTHER LEGALLY AUTHORIZED NAMES BY WHICH THE REGISTRANT MAY BE KNOWN.

4. TYPE OF FUND RAISING COUNSEL (CHECK ONE AND ENTER THE REQUIRED ORGANIZING INFORMATION)

CORPORATION

PARTNERSHIP

UNINCORPORATED ASSOCIATION

SOLE PROPR IETORS HIP

STATE AND COUNTY IN WHICH ORGANIZED: ...............................................................................

DATE ORGANIZED: ........................................................

5. ENTER T HE REQUIRE D INFORMATION FOR EACH CONTR ACT AND SUBC ONTRACT WITH A CH ARITABLE ORGANIZATION OR OTHER ENTITY TH AT

THE REGISTRANT ENTERED INTO WITHIN THE PAST 12 MONTHS, OR PROVIDED SERVICES UNDER DURING THE PAST 12 MONTHS, TO ACT AS A

FUND RAISING COUNSEL, EITHER WHOLLY OR PARTLY IN NEW YORK STATE.

NAME AND ADDRESS OF CONTRACTING

CONTRACT PERIOD

BRIEF DESCRIPTION OF ACTIVITIES/SERVICES

CHARITABLE ORGANIZATION OR OTHER ENTITY

(AS PER CONTRACT)

PROVIDED BY REGISTRANT

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FROM-

TO-

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"X" BOX, IF ATTACHMENTS ARE INCLUDED

PURSUANT TO EXECUTIVE LAW, NONCOMPLIANCE WITH REGISTRATION REQUIREMENTS IS A MISDEMEANOR IN NEW YORK STATE

CONTINUED ON REVERSE

PRIVACY NOTIFICATION

THE DEPARTMENT OF LAW'S CHARITIES BUREAU IS REQUIRED TO COLLECT THE FEDERAL SOCIAL SECURITY AND EMPLOYER IDENTIFICATION

NUMBERS OF ALL REGISTRANTS. THE AUTHORITY TO REQUEST AND MAINTAIN SUCH PERSONAL INFORMATION IS FOUND IN §5 OF THE TAX LAW.

DISCLOSURE BY YOU IS MANDATO RY. THE INFORMAT ION IS COLLECTED TO ENABLE THE DEPARTM ENT OF TAXATION AND FINANCE TO IDENTIFY

INDIVIDUALS, BUSINESSES AND OTHERS WHO HAVE BEEN DELINQUENT IN FILING TAX RETURNS OR MAY HAVE UND ERSTATED TH EIR TAX

LIABILITIES AND TO GENERALLY IDENTIFY PERSONS AFFECTED BY THE TAXE S ADMINISTERED BY THE COMM ISSIONER OF TAXATION AND

FINANCE. IT WILL BE USED FOR TAX ADMINISTRATION PURPOSES AND ANY OTHER PURPOSE AUTHORIZED BY THE TAX LAW, BUT WILL NOT BE

AVAILABLE TO THE PUBLIC. A WRITTEN EXPLANATION IS REQUIRED WHERE NO NUMBERS ARE PROVIDED. THIS INFORMATION WILL BE

MAINTAINED IN THE CHARITIES INFORMATION SYSTEM BY THE CHARITIES BUREAU AT THE FOLLOWING ADDRESS:

STATE OF NEW YORK, DEPARTMENT OF LAW, CHARITIES BUREAU, THE CAPITOL, ALBANY, NY 12224

Form Char 014 - Fund Raising Counsel Registration Statement - 2001

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