Charitable Law Section Office 614.466.3181 Fax 614.466.9788 150 East Gay Street, 23rd Floor Columbus, Ohio 43215-3130 www.OhioAttorneyGeneral.gov SOLICITATION CAMPAIGN FINANCIAL REPORT (Sections 1716.05 and 1716.07, Ohio Revised Code) This financial report is to be completed by Fund-raising Counsel that at any time have custody of contributions and Professional Solicitors for each solicitation campaign conducted on behalf of a charitable organization. Fund-raising Counsel and Professional Solicitors must file with the charity a financial report of the solicitation campaign on the anniversary of the commencement of a campaign lasting more than year and within 90 days after the campaign has been completed. Professional Solicitors must also file their reports with the Attorney General. Fund-raising Counsel must file their reports with the Attorney General within seven days after filing with the charity. PLEASE DO NOT LEAVE ANY FIELDS BLANK. IF NOT APPLICABLE, INDICATE 223N/A224. PLEASE PRINT OR TYPE. 1. (Name of Professional Solicitor or Fund-raising Counsel) (EIN) (Street Address of Principal Place of Business) (City) (State) (Zip) (Telephone Number) 2. (Name of Charitable Organization as Filed with the Attorney General222s Office) (Charity EIN) (Ohio AG Registration #) (Street Address of Principal Place of Business) (City) (State) (Zip) (Telephone Number) 3.Provide the dates of the solicitation campaign as previously filed on the Solicitation Notice:Start Date: End Date:(MM/DD/YY)(MM/DD/YY)4.Provide the date the contract was signed by the Professional Solicitor:(MM/DD/YY) 5.Is the campaign still ongoing? Yes NoIf no, please provide the date the solicitation campaign was completed:(MM/DD/YY) 6.Please check each of the applicable fund-raising methods used in the solicitation campaign. telephone solicitation internet solicitation sell coupon books mail solicitation sell advertising show or performance door-to-door solicitation sell other items special events DO NOT LEAVE ANY FIELDS BLANK American LegalNet, Inc. www.FormsWorkFlow.com Solicitation Campaign Financial Report Type of Report: Interim Final/Closing Amended For the solicitation period beginning (mm/dd/yy): and ending (mm/dd/yy): If this is an interim report, provide the date (mm/dd/yy) solicitation began in Ohio: PROVIDE EXACT NUMBERS 226 DO NOT ROUND AMOUNTS UP OR DOWN Total Campaign Ohio* 1. Gross Revenue (Do not include pledges not yet received.) 2. Expenses: (do not attach separate list of expenses) Professional solicitor fees Salaries, wages, commissions Contract service fees Show or performance fees Cost of goods sold to contributors Printing Postage/Shipping Telephone Rent/Utilities Advertising/Marketing Insurance Supplies/Equipment Licenses/Permits/Registration fees Professional/Legal/Accounting Fees Other (describe): Other (describe): Other (describe): Other (describe): Other (describe): Other (describe): Other (describe): Other (describe): Other (describe): Other (describe): Other (describe): Other (describe): Other (describe): 3. Total Expenses: 4. Net Proceeds (Gross Revenue minus Total Expenses): 5. Amount of Net Proceeds Retained by the Charitable Organization: 6. Amount of Net Proceeds Retained by the Professional Solicitor: 7. Percentage of Gross Revenue Retained by the Charitable Organization: (Amount retained by the Charitable Organization divided by gross revenue) 8. Percentage of Gross Revenue to be Retained by the Charitable Organization as Written in the Contract and Solicitation Notice: PROVIDE EXACT NUMBERS 226 DO NOT ROUND AMOUNTS UP OR DOW N A breakdown of gross receipts and expenses generated in Ohio must be provided if the contract between the professional solicitor and the charitable organization provides for a percentage of gross revenue to be received by the charitable organization that differs from state to state. - 2 - American LegalNet, Inc. www.FormsWorkFlow.com DO NOT LEAVE ANY FIELDS BLANK AFFIDAVIT STATE OF : SS: COUNTY OF : (Name of Professional Solicitor or Fund-raising Counsel) and further state as follows: 1. I am the individual who has completed the foregoing Solicitation Campaign Financial Report Form; 2. I have read the foregoing Report and know the contents thereof; 3. The report is true and correct to the best of my knowledge and belief; and 4. This Report is made for the purpose of complying with the provisions of Chapter 1716 of the Ohio Revised Code. 5. In accordance with Ohio Revised Code Section 1716.07(E), a copy of this report was provided to on (Name of Charitable Organization) (Date) 6. Enclosed a confirmation of receipt or other proof of mailing to the charitable organization. (Signature) Sworn to and subscribed before me this day of 20 . (Notary Public Signature) Seal (Printed Name) DO NOT LEAVE ANY FIELDS BLANK - 3 -I, , being first duly sworn (Typed or Printed Name) say that I am the (Title or Office) of American LegalNet, Inc. www.FormsWorkFlow.com