(Rev.4-08) COMMONWEALTH OF PENNSYLVANIA SOLICITATION CAMPAIGN/EVENT FINANCIAL REPORT - FORM BCO-165 Certificate #: ___________ Contract #: (FULL BUSINESS NAME) CONTRACT INFORMATION ____________ Full business name of Professional Solicitor as rgistered with the Department: 1. Name of charitable organization: 2. Effective and termination dates of contract : 3. Dates of campaign covered by this financial report:_______________________________________________________________ FINANCIAL REPORT 1. Total contributions (only report contributions received)......................................... 2. Total expenses (attach itemized list of all expenses) .................................................... 3. Net proceeds received by the charity or net loss incurred (line 1 minus line 2)............ 4. Any additional amount received by the charity. ................................................ Comments (e.g. disclose whether campaign commenced in other states prior to commencing in Pennsylvania): I do hereby declare that the information contained herein is true and correct to the best of my knowledge, information and belief and that if the percentage of total revenue received by the charitable organization is less than the guaranteed minimum percentage per the contract the charitable organization has agreed to accept said amount. DATE AUTHORIZED CONTRACTING AGENT FOR THE PROFESSIONAL SOLICITOR PRINT NAME AND TITLE OF CONTRACTING AGENT FOR THE PROFESSIONAL SOLICITOR DATE AUTHORIZED OFFICIAL OF THE CHARITABLE ORGANIZATION PRINT NAME AND TITLE OF AUTHORIZED OFFICIAL OF THE CHARITABLE ORGANIZATION DATE AUTHORIZED OFFICIAL OF THE CHARITABLE ORGANIZATION PRINT NAME AND TITLE OF AUTHORIZED OFFICIAL OF THE CHARITABLE ORGANIZATION INSTRUCTIONS ON REVERSE 9 American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 4-09) INSTRUCTIONS FOR COMPLETION OF THE SOLICITATION CAMPAIGN/EVENT FINANCIAL REPORT - FORM BCO-165 This report is required to be filed by the professional solicitor with the Bureau within 90 days after the completion of a solicitation campaign or event or on the anniversary of the commencement of a solicitation campaign lasting longer than one year. The report must be signed and sworn to by the authorized contracting agent for the professional solicitor and two different authorized officials of the charitable organization. The information to be provided must include financial information pertaining to total contributions received and expenses incurred with regards to all states in which the campaign was conducted. You may file an updated report for any campaign in which the campaign financial information reported on a prior financial report has changed due to additional contributions being received and/or expenses being incurred after the filing of a prior report. CONTRACT INFORMATION 1) NAME OF CHARITABLE ORGANIZATION: The name should be the same name as it appears in the written contract. 2) EFFECTIVE AND TERMINATION DATES OF CONTRACT: Enter the dates as stated in the contract. These dates may also be obtained from the Certificate Of Contract Registration that the Bureau sends upon the approval of the contract. 3) DATES OF CAMPAIGN COVERED BY THIS FINANCIAL REPORT: Dates must be specific dates and must include the Month/Day/Year. The dates are to be with regards to the campaign as conducted in Pennsylvania. In other words, an accounting is not required for dates in which no solicitation activity was conducted in Pennsylvania. If you elect to provide an accounting covering dates in which the campaign and/or event was not conducted in Pennsylvania, please state such in the "Comments" section of the report and indicate these additional dates. FINANCIAL REPORT 1) TOTAL CONTRIBUTIONS: Enter only the total contributions actually received. Do not report pledges that have not been received. 2) TOTAL EXPENSES: Report all expenses paid. Do not report any unpaid expenses or any contributions received by the charity that are to be reported on Line 3. An itemized list of all expenses must be attached which must include the compensation received by the professional solicitor, expenses paid by the professional solicitor, and any other expenses paid by the charitable organization. 3) NET PROCEEDS OR NET LOSS: This is the amount received by the charitable organization or the net loss incurred. Any net proceeds received by the charitable organization must exclude any expenses paid by the charitable organization that are to be reported on Line 2. 4) ANY ADDITIONAL AMOUNT RECEIVED BY CHARITY: For example, if a loss was incurred or if net proceeds are less than the minimum percentage guaranteed to the charity, report any revenue received by the charity given to satisfy the guaranteed minimum percentage. Do not report any amount already reported on Line 3. COMMENTS: Please provide any comments or explanation(s) regarding the campaign financial report you feel are necessary. If the report is an updated report of a report previously filed, please inform. 10 American LegalNet, Inc. www.FormsWorkFlow.com