Form Po 90-05 - 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
Ron Thornburgh
90-05
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
Name of professional fund raiser:
mail to the Kansas Secretary of State with
the filing fee. Selecting 'Print' will print
________________________________________________
the form and 'Reset' will clear the entire
Name
________________________________________________
form.
Street address
_________________________ __________ ___________
Do not write in this space
City
State
Zip
Name of charitable organization:
________________________________________________
Name
______________________________________ __________________________ ____________ ___________
Street address
City
State
Zip
Fund raising activity (actual or expected):
Beginning date: ______________________
_________________
_____________
Month
Day
Year
Ending date:
______________________
_________________
_____________
Month
Day
Year
_________________________________
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
Instruction
This form must be filed for any charitable organization before acting as a professional fund raiser for the
charitable organization.
Rev. 8/28/03 amc
K.S.A. 17-1764
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