Supplemental Solicitation Report - Washington Secretary Of State Page 2
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SECTION 3A (continued)
REQUIRED ENCLOSURE FOR ACCT YEAR REPORTED:
Enclose a complete copy of the IRS federal return (e.g. Form 990, 990-EZ or 990-PF) that the organization
filed with the IRS for the accounting year reported. Include all applicable Schedules and attachments, except
Schedule B/contributors list. A copy of the Form 990-N (e-Postcard) is not required. Do not enclose bank
statements or annual reports. Do not staple or bind federal return or its attachments.
If the organization’s IRS federal return is not finished yet, please contact the Charities Program for instructions.
TIP: Before completing Section 3B below, please review the Suggested Guidelines at
SECTION 3B (REQUIRED)
SOLICITATION REPORT FOR ACCOUNTING YEAR REPORTED:
(see instructions)
BEGINNING DATE OF FISCAL / ACCT YEAR
(mm/dd/yyyy)
ENDING DATE OF FISCAL / ACCT YEAR
(mm/dd/yyyy)
1. GROSS DOLLAR VALUE OF ALL CONTRIBUTIONS FROM SOLICITATIONS
$
+
2. GROSS DOLLAR VALUE OF REVENUE FROM ALL OTHER SOURCES
$
=
3. TOTAL DOLLAR VALUE OF GROSS RECEIPTS
$
4. GROSS DOLLAR VALUE OF EXPENDITURES FOR PROGRAM SERVICES
$
+
5
GROSS DOLLAR VALUE OF EXPENDITURES FOR ADMIN AND FUNDRAISING
$
.
6. TOTAL GROSS DOLLAR VALUE OF PROGRAM SERVICES, ADMINISTRATION
=
AND FUNDRAISING EXPENDITURES
$
7. BEGINNING GROSS ASSETS
$
8. ENDING GROSS ASSETS
$
(OPTIONAL) SOLICITATION COMMENTS
(if necessary, enclose additional sheet)
SECTION 4
SIGNATURE:
By signing this supplemental form, the applicant (a) certifies that the information contained in the form, and its
enclosures, are accurate and true to the best of the applicants knowledge; (b) irrevocably appoints the
Secretary of State to receive process (notice of lawsuit) in non-criminal cases against the applicant, and under
the conditions set out in RCW 19.09.305; and (c) certifies that neither the organization nor any of its officers,
directors, and principals have been convicted of a crime involving charitable solicitations, nor been subject to a
permanent injunction or administrative order under the Washington Consumer Protection Act (Chapter 19.86
RCW) in the past 10 years.
X ________________________________ ____________________________ _________ _____________
Signature of Applicant
Printed Name / Title
Date
Phone
This form must be signed and dated by the organization’s President, Treasurer or a comparable officer (see instructions).
ALL SUBMISSIONS ARE SUBJECT TO PUBLIC REVIEW
Mail to: Secretary of State, Charities Program, PO Box 40234, 801 Capitol Way S Olympia, WA 98504-0234
Charitable Organization Supplemental
Washington Secretary of State
Revised 11/2010
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