The State of South Carolina Office of the Secretary of State Public Charities Division P. O. Box 11350 Columbia, SC 29211 CHARITABLE SOLICITATION QUESTIONNAIRE To be completed only by the person who actually spoke with the person soliciting for a charity. The information you provide may become a matter of public record. Please return your completed questionnaire as soon as possible. Fax: (803) 734-1604 Mailing Address: Post Office Box 11350, Columbia SC 29211. Your Name: ___________________________________________________________________ Your Address: _________________________________________________________________ City, State Zip: ________________________________________________________________ Telephone: ____________________________________________________________________ Number where you received the solicitation, if different from above: ______________________ PLEASE USE BACK OF THIS SHEET, IF ADDITIONAL INFORMATION IS NEEDED. 1. Name of the Charitable Organization by whom you were solicited: ___________________________________________________________________________ How did you find out this name? ___________________________________________________________________________ 2. Date of Solicitation: __________________________________________________________ 3. Time of Solicitation, if known: _________________________________________________ 4. With whom did you think you were speaking? What led you to that conclusion? ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com 5. Did the Solicitor identify him/herself? Circle one: YES NO 6. If so, what was his/her name? __________________________________________________ 7. Without being asked, did the solicitor say whether he/she was a “paid” or “professional” solicitor? Circle one: YES NO 8. Without being asked, did the solicitor, if paid, identify the company for whom he/she worked? Circle one: YES NO 9. If the company was given, what was its name? ___________________________________________________________________________ 10. Without being asked, did the solicitor tell you where the charity was located? Circle one: YES NO 11. If YES, where did the solicitor indicate the charity was located? ___________________________________________________________________________ 12. Without being asked, did the solicitor tell you the purpose of the organization and how your contribution would be used? Circle one: YES NO If YES, please describe below: ___________________________________________________________________________ ___________________________________________________________________________ 13. Did you ask the solicitor to send you information about the organization before agreeing to donate? Circle one: YES NO If YES, what information was requested? _________________________________________ What information was sent? ___________________________________________________ 14. Did you inquire about the percentage of the donation that would go to the solicitor? Circle one: YES NO If YES, what was the response? _________________________________________________ 2 American LegalNet, Inc. www.USCourtForms.com 15. Did you inquire about the percentage of the donation that would go to the charity? Circle one: YES NO If YES, what was the response? _________________________________________________ 16. Did you feel that the solicitor made any misrepresentations or mislead you in any way? Circle one: YES NO If YES, please explain: _______________________________________________________ ___________________________________________________________________________ 17. Did you make a pledge to the charity? Circle one: YES NO If YES, how much? $$ ________ 18. Did you contribute? Circle one: YES NO 19. Please attach any additional comments you may have regarding this solicitation. IF YOU HAVE COPIES OF RECEIPTS, LETTERS, ETC. IN CONNECTION WITH THIS SOLICITATION, PLEASE INCLUDE THEM WITH THIS QUESTIONNAIRE. THANK YOU. YOUR SIGNATURE: ______________________________________ DATE: _____________ 3 American LegalNet, Inc. www.USCourtForms.com