Securities and Charities Division Office of the Georgia Secretary of State 2 Martin Luther King Jr. Drive SE Suite 820 West Tower - Atlanta, GA 30334 (478) 207-2440 http://www.sos.ga.gov Brian P. Kemp Secretary of State Financial Report of Campaign GEORGIA CHARITABLE SOLICITATIONS ACT OF 1988, AS AMENDED O.C.G.A. 43-17-3(h) Noula Zaharis Division Director A. GENERAL INFORMATION Full name of Paid Solicitor Business address Name and Business address of charitable organization/sponsor with whom contracted Registration Number of charitable organization Date of the commencement of the campaign Telephone Number City City Registration Number Sate State Zip Code Zip Code Telephone Number of Charitable Organization Date of completion of campaign or, if still in progress, provide dates covered by this report Fundraising methods used in this campaign (mark all that apply) Telephone Direct Sale of goods Door to door appeal Mail or services solicitation List the areas of the state targeted by the campaign: Other: (please describe) B. CAMPAIGN FINANCIAL REPORT a. Gross Revenue: b. Expenses Paid solicitor fee Salaries, wages, commissions Promotional Fees Show or performance fee Security Printing Postage Telephone Rent Utilities Total expenses Insurance Supplies Licenses, permits Bank charges Advertising (employment) Other (itemize) NET AMOUNT PAID TO CHARITABLE ORGANIZATION OR SPONSOR: (This figure is, in essence, the profit to the charitable organization after all expenses, regardless of who is or was responsible for paying them and regardless of whether they have actually been paid yet.) PERCENTAGE OF FUNDS RECEIVED BY CHARITABLE ORGANIZATION OR SPONSOR: (Amount retained by the charitable organization or sponsor divided by gross revenue.) INDICATE THE TOTAL AMOUNT OF UNCOLLECTED PLEDGES AS OF THE DATE OF THIS REPORT: I state that the above information is true and accurate and I understand that a false statement on this form may subject me to a criminal fine and/or imprisonment. Signature and Title of Official of Paid Solicitor Date Signature and Title of Official of Charitable Organization Date NOTE: THIS FORM MUST BE SIGNED BY AN AUTHORIZED REPRESENTATIVE OF THE CHARITABLE ORGANIZATION. Form S300 Revised Aug 2012 American LegalNet, Inc. www.FormsWorkFlow.com