(Rev.4-08) TELEPHONE: (717) 783-1720 (1) 800-732-0999 (WITHIN PA) FAX (717) 783-6014 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF CHARITABLE ORGANIZATIONS 207 NORTH OFFICE BUILDING HARRISBURG, PENNSYLVANIA 17120 SOLICITATION NOTICE ADDENDUM - FORM BCO-170A Business name and address of professional solicitor as registered with the Bureau: FULL BUSINESS NAME ADDRESS CITY STATE ZIP CODE CITY NO FEE Legal name and address of charitable organization as registered with the Bureau: FULL LEGAL NAME ADDRESS STATE ZIP CODE 1. Describe the solicitation campaign or event. Indicate the dates the solicitation campaign or event began or will begin and when it will terminate in Pennsylvania. If the campaign involves a show, circus, performance or similar event,, provide the address and seating capacity of the facility where the event will be held and the time and date of each performance: 2. Is the charitable organization currently registered with the Bureau to solicit contributions? Yes _____ No _____ If No, is the charitable organization exempt from registration? Yes _____ No _____. 3. Describe the charitable programs/purposes for which the contributions raised will be used by the charitable organization. If the contributions are to be used for the overall programs or purposes of the charity, you may simply include the charitable organization's stated mission or purpose. 4. Will you the professional solicitor, or anyone acting on your behalf have custody or control of contributions at any time? No Yes 5. The account number and location of each bank account(s) where receipts from the campaign will be deposited ( you may have to obtain this information from the charity.) 6. Is the bank account(s) referred to in Item 5 in the name of the charitable organization and does the charitable organization No maintain and administer the account and have sole control of all withdrawals? Yes 7. Give each location and telephone number from which the solicitation will be conducted: 8. Attach a list providing the legal name and residence address of each person responsible for directing and supervising the conduct of the campaign and each person who will solicit during such campaign. Please indicate which individuals are directors or supervisors. I, the authorized contracting officer for the professional solicitor, do hereby declare that the information contained herein is true and correct to the best of my knowledge, information and belief. AUTHORIZED CONTRACTING OFFICER FOR PROFESSIONAL SOLICITOR PRINT NAME AND TITLE OF AUTHORIZED CONTRACTING OFFICER DATE 12 American LegalNet, Inc. www.FormsWorkFlow.com