Form Sc 53-10 - Registration Statement For Solicitations (Page 3 of 3) in pdf

Form Sc 53-10 - Registration Statement For Solicitations Page 3

19. Is this organization, or has it ever been, enjoined by any court from soliciting contributions?

Yes

If yes, explain in detail:

20. Organization’s tax year end: _____________________

_______________________

__________________

month

day

year

21. If renewing, report the costs of fund raising incurred during the last fiscal year. New registrants should report the costs anticipated to

be incurred by the organization in the current or upcoming year. A statement of such costs as a percentage of contributions received must

be included.

For fiscal year:

List all costs - describe below:

___ ___ ___

Total costs:

Total costs as a percent of contributions received:

(Attach additional pages, if necessary)

22. Attach a financial statement (form provided) covering complete disclosure of the fiscal activities of the organization during the preceding

year. The Secretary of State will accept executed copies of federal IRS returns and reports in lieu of a financial statement. If the

organization received contributions exceeding $100,000, an audited financial statement prepared in accordance with generally accepted

accounting principles and an opinion of an independent CPA on the financial statement must be filed.

THIS STATEMENT MUST BE SIGNED BY TWO SEPARATE, AUTHORIZED OFFICERS, ONE OF WHOM

MUST BE THE CHIEF FISCAL OFFICER.

I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.

Executed on this _________ of ___________________________ , ________ .

Day

Month

Year

Name (printed or typed)

Authorized officer

Name (printed or typed)

Chief fiscal officer

Instructions

1. Submit this registration statement and financial statement, with a $35 registration.

2. Solicitation registration expires on the last day of the sixth month following the month in which the fiscal

year of charitable organization ends.

3. Solicitation registration must be renewed each year.

Notice: There is a $25 service fee for all returned checks.

Rev. 4/20/05 jls

K.S.A. 17-1763

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Form Sc 53-10 - Registration Statement For Solicitations Page 3