Form Cts-10 - Charitable Solicitation Campaign Financial Statement

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State of Michigan
AUTHORITY: 1975 PA 169
Department of Attorney General
Charitable Trust Section
Charitable Solicitation Campaign Financial Statement
Legal Name of Professional Fundraiser:
Legal Name of Charity:
MIFR Number:
MICS Number or EIN:
Period covered by this report: ____________________ to ____________________
Type of Report:
Final Report
Annual or Interim Report
Part I. General Information
A. Fundraising Methods used in this campaign (mark all that apply):
Internet/Social media
Special event
Direct mail
Other (describe): ___________
Vehicle donations
Door to door
B. Books and records of this campaign are in the care of:
___________________________ State: _____________ Zip Code: __________
Part II. Financial Information
Report amounts from entire campaign, not just Michigan. Include all revenues and costs of any sub-
contractors. Net amount to charity on line D should be after all costs of campaign have been
deducted, including any costs contracted or incurred separately by the charity.
A. Gross receipts collected in campaign:
$ ________________________
B. All campaign costs paid to, or retained by, PFR:
$ ________________________
C. Campaign costs, not included on B, incurred by charity:
$ ________________________
D. Net amount to charitable organization:
$ ________________________
The sum of lines B, C, and D
must equal line A. However, if
line D would be a negative
number, only enter the negative
Attach a schedule itemizing expenses of the campaign deducted
number if the charity incurred
to determine net amount to charity.
the loss on the campaign.
Otherwise, enter zero.
Part III. Certification
By clicking this box, I certify that the statements and information on this Campaign
Financial Statement and the attached schedule of itemized expenses have been reviewed by
both the above-named Professional Fundraiser and charity and are accurate, complete, and
true. False statements are prohibited by MCL 400.288(1)(u) and MCL 400.293(2)(c) and
are punishable by civil and criminal penalties.
Print Your Name:
Name of Organization:
Revised 5/11/15


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