Form Char012 - Professional Solicitor Registration Statement Page 3
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5Part G - Private Information - NOT OPEN TO PUBLIC INSPECTION
1. Registrant’s legal name as specified in Part A1
2. Registrant’s Social Security Number
3. Registrant’s Federal Employer Identification Number
____ ____ ____ - ____ ____ - ____ ____ ____ ____
____ ____ - ____ ____ ____ ____ ____ ____ ____
4. Explanation required if no Social Security Number or Federal Employer ID Number provided
PRIVACY NOTIFICATION
The New York State Office of the Attorney General’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 New York Tax Law. Disclosure
by the registrant is mandatory. The information is collected to enable the New York State Department of Taxation and Finance to identify
individuals, businesses and others who have been delinquent in filing tax returns or may have understated their tax liabilities and to generally identify
persons affected by the taxes administered by the Commissioner 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 by the Attorney General’s Charities Bureau at the address at the top of Page 1 of this form.
Page 3 of 3
Form CHAR012 (2010)
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