Form Bco-165 - Solicitation Campaign/event Financial Report - Commonwealth Of Pennsylvania
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2COMMONWEALTH OF PENNSYLVANIA
SOLICITATION CAMPAIGN/EVENT FINANCIAL REPORT - FORM BCO-165
(Rev.4-08)
Full business name of Professional Solicitor
Certificate #: ___________
as rgistered with the Department:
Contract #: ____________
(FULL BUSINESS NAME)
CONTRACT INFORMATION
1. Name of charitable organization:
2. Effective and termination dates of contract :
3. Dates of campaign covered by this financial report:_______________________________________________________________
FINANCIAL REPORT
1. Total contributions (only report contributions received)..……..............……………....
2. Total expenses (attach itemized list of all expenses) ..…………..............................……..
3. Net proceeds received by the charity or net loss incurred (line 1 minus line 2).….…….
4. Any additional amount received by the charity. ………..……………………………….
Comments (e.g. disclose whether campaign commenced in other states prior to commencing in Pennsylvania):
I do hereby declare that the information contained herein is true and correct to the best of my knowledge,
information and belief and that if the percentage of total revenue received by the charitable organization is less than
the guaranteed minimum percentage per the contract the charitable organization has agreed to accept said amount.
DATE
AUTHORIZED CONTRACTING AGENT
PRINT NAME AND TITLE OF CONTRACTING
FOR THE PROFESSIONAL SOLICITOR
AGENT FOR THE PROFESSIONAL SOLICITOR
DATE
AUTHORIZED OFFICIAL OF THE
PRINT NAME AND TITLE OF AUTHORIZED
CHARITABLE ORGANIZATION
OFFICIAL OF THE CHARITABLE ORGANIZATION
DATE
AUTHORIZED OFFICIAL OF THE
PRINT NAME AND TITLE OF AUTHORIZED
CHARITABLE ORGANIZATION
OFFICIAL OF THE CHARITABLE ORGANIZATION
INSTRUCTIONS ON REVERSE
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