Form Po - Professional Fund Raiser Operating Statement
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1Contact Information
KANSAS SECRETARY OF STATE
PO
Kansas Secretary of State
Professional Fund Raiser Operating Statement
Memorial Hall, 1st Floor
90-05
120 S.W. 10th Avenue
All information must be completed or this document will not be accepted for filing.
Topeka, KS 66612-1594
(785) 296-4564
kssos@sos.ks.gov
1. Name of professional fund raiser:
______________________________________________
_______________________________________
2. Address:
Street address
_________________________ ________ ___________
Do not write in this space
City
State
Zip
3. Name of charitable organization:
______________________________________________
Name
______________________________________ __________________________ ____________ __________
Street address
City
State
Zip
4. Fund raising activity (actual or expected):
Beginning date: _______________________ _________________ _____________
Month
Day
Year
Ending date:
_______________________ _________________
_____________
Month
Day
Year
_________________________________
5. Date of this report:
I declare (or verify, certify or state) under penalty of perjury under the laws of the state of Kansas that the foregoing
is true and correct. Executed on this ________ day of ____________________________ , _______ .
Day
Month
Year
Name (printed or typed)
Authorized signature(s) of professional fund raiser (proprietor, or all partners,
or corporate officer and title).
Title/position
Instructions
This form must be filed for any charitable organization before acting as a professional fund raiser for the
charitable organization.
Rev. 12/28/10 jdr
K.S.A. 17-1764
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