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 Georgia Charitable Solicitations Act Solicitation Notice Filing Instructions Noula Zaharis Division Director 1. 2. 3. 4. Complete form in full Attach a copy of contract between paid solicitor and charitable organization Attach filing fee payable to the Secretary of State in the amount of $15.00 (non refundable) Submit end of campaign financial report as prescribed by OCGA 43-17-3(g) WARNING: A paid solicitor may not solicit charitable contributions in the State of Georgia until this notice is properly completed including attachment(s) and filed with the Secretary of State pursuant to OCGA 43-17-3(f). Failure to file this notice may subject the paid solicitor to sanctions and penalties provided for the in the Georgia Charitable Solicitations Act of 1988, as amended. 1. Name and Address of Paid Solicitor Contact Person: Telephone #: SOS Registration Number 2. Name and Address of the Charitable Organization Contact Person: Telephone #: NOTE: If charity is exempt from registration with the Secretary of State, please indicate the basis for the exemption SOS Registration Number 3. Date Solicitation Campaign will begin: 4. Date Solicitation Campaign will end: 5. Will the Paid Solicitor, at any time, have custody of contributions? Yes No 6. The following documents must be attached to this notice: a. copy of the solicitation contract b. full and fair description of the charitable program for which the solicitation campaign is being performed. c. list of the locations and telephone numbers from where the solicitations will be conducted d. the name and residence address of each person responsible for directing and supervising the conduct of the campaign The undersigned, on behalf of the paid solicitor, represents that the information and statements contained herein including the exhibits attached hereto, and other information files herewith, all of which are a part hereof, are current, true and complet e. Authorized Signature: Print Name and Title of Person Signing: Form S200 Revised Aug 2012 American LegalNet, Inc. www.FormsWorkFlow.com