Form Fs 53-10 - Charitable Solicitation Financial Statement
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1Fees will increase September 1, 2003. If you file this report
before September 1, the fee is NA. If you file this report after
September 1, the fee is $35.00.
Contact Information
KANSAS SECRETARY OF STATE
FS
Kansas Secretary of State
Charitable Solicitation Financial Statement
Ron Thornburgh
53-10
Memorial Hall, 1st Floor
All information must be completed or this document will not be accepted for filing.
120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-4564
Print
Reset
Please complete the form, print, sign and
Period covering ______________________ to ______________________ .
mail to the Kansas Secretary of State with
the filing fee. Selecting 'Print' will print
Gross receipts:
(Attach a listing of total receipts and income
the form and 'Reset' will clear the entire
for each separate solicitation project/source)
form.
Solicitations expenses:
(
)
Do not write in this space
Net profit:
Administrative expenses:
(
)
Operating income:
Educational/informational program expenses:
(
)
Other expenses:
(
)
Net income:
Charitable distributions in Kansas:
(
)
Charitable distributions outside of Kansas:
(
)
(Attach a listing of non-Kansas recipients of
distributions and such recipients’ purposes)
Other distributions:
(
)
Balance this period:
Beginning balance:
Ending balance:
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Executed by me on ____________ ________ , _________
.
Month
Day
Year
Authorized officer
Chief fiscal officer
Instruction
1. Submit this form with bond and the $35 filing fee.
Notice: There is a $25 service fee for all returned checks.
Rev. 8/11/03 jb
K.S.A. 17-1763
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