Form Bco-170a - Solicitation Notice Addendum
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1(Rev.4-08)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF STATE
BUREAU OF CHARITABLE ORGANIZATIONS
TELEPHONE: (717) 783-1720
207 NORTH OFFICE BUILDING
(1) 800-732-0999 (WITHIN PA)
HARRISBURG, PENNSYLVANIA 17120
FAX (717) 783-6014
SOLICITATION NOTICE ADDENDUM - FORM BCO-170A
NO FEE
Business name and address of professional solicitor
Legal name and address of charitable organization
as registered with the Bureau:
as registered with the Bureau:
FULL BUSINESS NAME
FULL LEGAL NAME
ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
1. Describe the solicitation campaign or event. Indicate the dates the solicitation campaign or event began or will begin and when it
will terminate in Pennsylvania. If the campaign involves a show, circus, performance or similar event,, provide the address and
seating capacity of the facility where the event will be held and the time and date of each performance:
2. Is the charitable organization currently registered with the Bureau to solicit contributions? Yes _____ No _____
If No, is the charitable organization exempt from registration? Yes _____ No _____.
Describe the charitable programs/purposes for which the contributions raised will be used by the charitable organization. If
3.
the contributions are to be used for the overall programs or purposes of the charity, you may simply include the charitable
organization's stated mission or purpose.
4. Will you the professional solicitor, or anyone acting on your behalf have custody or control of contributions at any time?
Yes
No
5. The account number and location of each bank account(s) where receipts from the campaign will be deposited ( you may have to
obtain this information from the charity.)
6. Is the bank account(s) referred to in Item 5 in the name of the charitable organization and does the charitable organization
maintain and administer the account and have sole control of all withdrawals? Yes
No
7. Give each location and telephone number from which the solicitation will be conducted:
8. Attach a list providing the legal name and residence address of each person responsible for directing and supervising the
conduct of the campaign and each person who will solicit during such campaign. Please indicate which individuals are
directors or supervisors.
I, the authorized contracting officer for the professional solicitor, do hereby declare that the information
contained herein is true and correct to the best of my knowledge, information and belief.
AUTHORIZED CONTRACTING OFFICER
PRINT NAME AND TITLE OF
FOR PROFESSIONAL SOLICITOR
AUTHORIZED CONTRACTING OFFICER
DATE
12
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