Form Char 014 - Fund Raising Counsel Registration Statement printable pdf download

CHAR 014

FOR OFFICE USE ONLY

STATE of NEW YORK

DATE REC’D.

AMOUNT

Fund Raising Counsel

OFFICE of the ATTORNEY GENERAL

CHARITIES BUREAU

Registration Statement

CASH BK.#

REG. NO.

THE CAPITOL

ALBANY, NY 12224

DATE ACCT.

EXAMINED BY

FOR YEAR ENDING AUGUST 31, 20

INSTRUCTIONS: Type or print in ink the answers to all applicable items on both sides of this

form. (Enter "NA" for any item that is not applicable.) In all cases, "the firm" shall mean the applicant Fund Raising Counsel named in Item 1;

"representative of the firm" shall mean a principal, director or officer of the firm. This fully executed statement, along with the mandatory fee of

$800 (Art. 7-A, Exec. Law), in the form of a check or money order made payable to the "Department of Law", should be sent to the above

address. Please be sure to sign this statement where indicated and include all attachments, clearly labelled to reference any item requiring additional

explanation.

NOTE: The Charities Bureau must be notified in writing within 20 days, if any changes to the information provided in this statement occur during

the period of registration (Art. 7-A, Exec. Law).

1. FULL, OFFICIAL NAME OF FUND RAISING COUNSEL (IF COMPANY, USE COMPANY NAME/ADDRESS)

TELEPHONE NUMBER

(

)

PRINCIPAL STREET ADDRESS

CITY, STATE, ZIP

2. PRINCIPAL NEW YORK STATE ADDRESS, IF ANY (IF NOT THE SAME AS ITEM 1)

3. A. DO YOU OR ANY REPRESENTATIVE OF THE FIRM SOLICIT, AS THAT TERM IS DEFINED IN §171-A OF ARTICLE 7-A

OF THE EXECUTIVE LAW?..................................................................................................................................................................................

YES

B. DO YOU OR ANY REPRESENTATIVE OF THE FIRM HAVE ACCESS TO CONTRIBUTIONS OR OTHER RECEIPTS FROM

SOLICITATIONS?...................................................................................................................................................................................................

YES

C. DO YOU OR ANY REPRESENTATIVE OF THE FIRM HAVE AUTHORITY TO PAY EXPENSES ASSOCIATED WITH A

SOLICITATION?.....................................................................................................................................................................................................

YES

4. TYPE OF FUND RAISING COUNSEL (CHECK ONE AND COMPLETE)

CORPORATION -- State in which incorporated:

Date:

PARTNERSHIP -- County and state in which organized:

Date:

INDIVIDUAL -- County and state in which organized:

Date:

5. LIST NAMES AND ADDRESSES OF THE CHARITABLE OR OTHER ORGANIZATIONS WITH WHICH THE FIRM PRESENTLY HAS CONTRACTS, OR HAS

CONTRACTED WITH IN THE PAST 12 MONTHS, TO ACT AS A FUND RAISING COUNSEL, EITHER WHOLLY OR PARTLY IN NEW YORK STATE.

NAME AND ADDRESS OF ORGANIZATION

PERIOD COVERED

DESCRIPTION OF ACTIVITY

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"X" BOX, IF ATTACHMENTS ARE INCLUDED

PURSUANT TO EXECUTIVE LAW, NONCOMPLIANCE WITH REGISTRATION REQUIREMENTS IS A MISDEMEANOR IN NEW YORK STATE.

CONTINUED ON REVERSE

This form (including attachments) is a public record and a copy will be provided, upon request, to any interested person.

PRIVACY NOTIFICATION

THE DEPARTMENT OF LAW’S CHARITIES BUREAU IS REQUIRED TO COLLECT THE FEDERAL SOCIAL SECURITY AND EMPLOYER

IDENTIFICATION NUMBERS OF ALL REGISTRANTS. THE AUTHORITY TO REQUEST AND MAINTAIN SUCH PERSONAL INFORMATION

IS FOUND IN §5 OF THE TAX LAW. DISCLOSURE BY YOU IS MANDATORY. THE INFORMATION IS COLLECTED TO ENABLE THE

DEPARTMENT OF TAXATION AND FINANCE TO IDENTIFY INDIVIDUALS, BUSINESSES AND OTHERS WHO HAVE BEEN DELINQUENT

IN FILING TAX RETURNS OR MAY HAVE UNDERSTATED THEIR TAX LIABILITIES AND TO GENERALLY IDENTIFY PERSONS AFFECTED

BY THE TAXES ADMINISTERED BY THE COMMISSIONER OF TAXATION AND FINANCE. IT WILL BE USED FOR TAX ADMINISTRATION

PURPOSES AND ANY OTHER PURPOSE AUTHORIZED BY THE TAX LAW, BUT WILL NOT BE AVAILABLE TO THE PUBLIC. A WRITTEN

EXPLANATION IS REQUIRED WHERE NO NUMBERS ARE PROVIDED. THIS INFORMATION WILL BE MAINTAINED IN THE CHARITIES

INFORMATION SYSTEM BY THE CHARITIES BUREAU AT THE FOLLOWING ADDRESS:

STATE OF NEW YORK, OFFICE OF THE ATTORNEY GENERAL, CHARITIES BUREAU, THE CAPITOL, ALBANY, NY 12224

Form Char 014 - Fund Raising Counsel Registration Statement

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