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Form 10a - Form Of Addendum To Registration Statement To Be Filed By Professional Solicitors Page 3

Form 10A

Anticipated duration of solicitation (MM/DD/YYYY).

Starting date:

Ending date:

Projected gross receipts to be raised by this solicitation:

This figure is (check one):

Stated in written contract/agreement

Estimate/estimate range not stated in contract

10.

Approximate percentage of gross receipts that the charitable

organization will receive or retain:

This figure is (check one):

Stated in written contract/agreement

Estimate/estimate range not stated in contract

11.

If prospective contributors ask how much of their contributions will go to the charitable

organization, what will they be told?

12(A). Place an “X” in the box to the right if the professional solicitor, or its agents or

employees will handle receipts.

12(B). Indicate the type of professional fund-raiser by writing the corresponding code in the box to

the right:

Deposit/withdrawal by solicitor only

Deposit by solicitor, withdrawal by solicitor or charity

Deposit by solicitor, withdrawal by charity only

Deposit/withdrawal by charity only

Other (please explain):

12(C).

If the professional solicitor is able to withdraw funds under the arrangement indicated in 12(B),

provide the following information.

Bank in which charitable funds held:

Account number:

Bank address (Street No. and Name):

Bank address (City, State, Zip Code):

Form 10A

Page 3 of 6

Rev. 07/2007

Form 10a - Form Of Addendum To Registration Statement To Be Filed By Professional Solicitors Page 3