ACTIVITY STATEMENTS
This Section is required of ALL organizations.
1.
Have your books/records been audited by or for any government agency/funding source this fiscal year?
YES ________ NO _________
If YES, specify agency: ____________________________________________________________________.
Period audited: from __________________________ to _______________________________.
2.
Does your organization allocate costs of multi-purpose activities between Program Services, Management and General,
and Fundraising, i.e. Direct Mail, Telethon? YES ______ NO ______
3.
Did your organization receive donated services or the use of materials, equipment, or facilities at no charge or at a
substantially less than fair rental value? YES ______ NO _______
If YES, indicate the value: _________________. (Do NOT include this amount as support or as an expense on the
Financial Summary.)
SCHEDULE 1: CONTRIBUTIONS
This Section is required of ALL organizations.
BEFORE doing this Schedule, do Schedule 2, 3, 4 or 5 if applicable to your organization.
Do NOT report donated services or facilities on this schedule.
PORTION
TOTAL
IN-KIND
Direct Public Support
1.
Direct Mail................................................................................................... ________________
______________
2.
Telephone Solicitation Campaign................................................................ ________________
______________
3.
Commercial Co-Venture (Complete Schedule 4) ........................................ ________________
______________
4.
Door-to-Door ............................................................................................... ________________
______________
5.
Special Events & Fundraising Sales (Complete Schedule 5) ...................... ________________
______________
6.
Telethons ..................................................................................................... ________________
______________
7.
Foundation and Trust Grants ....................................................................... ________________
______________
8.
Corporate and Business Grants or Sponsorships.......................................... ________________
______________
9.
Legacies and Bequests................................................................................. ________________
______________
10. Other (Specify):
a. _____________________________________________ .................... ________________
______________
b. _____________________________________________ .................... ________________
______________
c. _____________________________________________ .................... ________________
______________
d. _____________________________________________ .................... ________________
______________
11. Total Direct Public Support (Add Lines 1 through 10d. Then
transfer amount on this line to the Financial Summary, Line 1.).................. ________________
______________
Indirect Public Support
12. From Federated Fundraising Agencies.......................................................... ________________
______________
13. From Affiliates............................................................................................... ________________
______________
14. From other Fundraising Agencies ................................................................ ________________
______________
15. Total Indirect Public Support (Add Lines 12 through 14. Then
transfer amount on this line to the Financial Summary, Line 2.) ................ ________________
______________
Government Grants
16. Specify agency:
a. _____________________________________________ .................... ________________
______________
b. _____________________________________________ .................... ________________
______________
c. _____________________________________________ .................... ________________
______________
d. _____________________________________________ .................... ________________
______________
17. Total Government Grants (Add Lines 16a through 16d. Then
transfer amount on this line to the Financial Summary, Line 3.)................. ________________
______________
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