TITLE 14: COMMERCE
SUBTITLE B: CONSUMER PROTECTION CHAPTER II: ATTORNEY GENERAL
PART 400
SOLICITATION FOR CHARITY ACT
SECTION 400.APPENDIX D PROFESSIONAL FUND RAISING CONSULTANT FORMS
Section 400.APPENDIX D Professional
Fund Raising Consultant Forms
Section 400.ILLUSTRATION A Registration
Statement
Form
PFC-01
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PROFESSIONAL
FUNDRAISING CONSULTANT
– REGISTRATION STATEMENT –
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Jim Ryan
Attorney General
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PLEASE
TYPE OR PRINT IN BLACK INK. Respond to all items. If unable to answer in
space provided attach a schedule in the same format. Changes of or additions
to the information in this statement are to be submitted in this format. All
consultants must attach an affidavit attesting that the professional fund
raising consultant has not or will not at any time have custody or control of
charitable contributions. Copies of all fund raising contracts must be
submitted to this Office within ten (10) days of signing. If any of the
information in this statement changes, this Office must be notified in
writing within 10 days of the changes. All contracts between professional
fund raising consultants and charitable organizations must be in writing and
filed by the PFR with the Attorney General within ten (10) days of execution.
Contracts shall contain the charity's legal name, their registration number,
a street address, a contact party and that party's daytime telephone number.
Changes or additions to the information in this statement must be submitted
on this form. One copy of this Registration Statement and attachments are to
be filed with the Office of the Attorney General, Charitable Trust and
Solicitations Bureau, 100 West Randolph Street, Chicago, Illinois 60601.
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1.
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THIS
IS A (CHECK ONE and DATE):
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NEW
REGISTRATION ( ) REREGISTRATION ( ) CHANGE ( ) ADDITON ( ) AS OF
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2.
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LEGAL NAME
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REGISTRATION/REREGISTRATION
For
Two (2) Years Upon Filing with the Attorney General
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3.
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MAIL ADDRESS
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PFR
NUMBER
11-
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CITY, STATE, ZIP CODE
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PHONE
NUMBER
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FEDERAL
ID NUMBER
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4.
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TYPE OF FIRM (Individual, Partnership or Corporation)
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5.
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WHERE and WHEN ORGANIZED (Corporations must ATTACH
Charter & Articles)
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6.
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NAME OF MANAGEMENT PERSON & PRESIDENT
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TITLE
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7.
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A STREET ADDRESS (if different than above)
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8.
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NAME OF ILLINOIS REGISTERED AGENT
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9.
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AGENT'S MAIL ADDRESS (if P.O. BOX also a street
address)
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10.
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GIVE PRINCIPAL ILLINOIS ADDRESS, IF ANY, AT WHICH
RECORDS ARE KEPT AND NAME OF CUSTODIAN (NOT A P.O. BOX)
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11.
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LIST ALL BUSINESS LOCATIONS, OTHER THAN ABOVE, USED
FOR FUNDRAISING. (ATTACH SCHEDULE INDICATING ACTIVITY DESCRIPTION,
STREET ADDRESS, CITY, STATE and if temporary location BEGINNING and ENDING
USE DATES.)
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12.
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IF NAME IN ABOVE IS NOT THE CORPORATE or ONLY NAME
USED BY THE REGISTRANT ATTACH SCHEDULE AND DOCUMENTS TO SUPPORT LEGAL
USE OF OTHER NAMES (e.g., REGISTRATION UNDER THE ASSUMED NAME ACT)
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13.
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ILLINOIS SECRETARY OF STATE'S CORPORATE FILE NO.
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IF A FOREIGN CORPORATION ATTACH A COPY OF
AUTHORIZATION.
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14.
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LIST ALL PRINCIPAL PARTIES, OFFICERS, DIRECTORS,
EXECUTIVE PERSONNEL, AND OWNERS OF TEN PERCENT OR MORE OF THE CAPITAL STOCK.
(ATTACH SCHEDULE IF NECESSARY)
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NAME STREET ADDRESS
TITLE % OF INTEREST BIRTH DATE DRIVERS LICENSE # STATE OF
ISSUE
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15.
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LIST THE INTEREST OF ALL PRINCIPAL PARTIES, OFFICERS,
DIRECTORS, EXECUTIVE PERSONNEL, OWNERS OF REGISTRANT AND THEIR FAMILY MEMBERS
HAVING ANY OWNERSHIP INTEREST IN ANY OTHER FIRMS PROVIDING GOODS OR SERVICES
USED IN FUNDRAISING
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NATURE OF BUSINESS
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NAME of PARTY
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% INTEREST
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NAME and STREET ADDRESS OF BUSINESS
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16.
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LIST THE INFORMATION REQUESTED BELOW FOR ALL
CHARITABLE ORGANIZATIONS HAVING CONTRACTS WITH THIS FIRM FOR THE PERIOD OF
THIS REGISTRATION OR CURRENTLY IN EFFECT INVOLVING THE RAISING OF FUNDS IN
ILLINOIS AND ATTACH COPIES OF THE CONTRACTS.
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ILLINOIS CO #
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LEGAL NAME and STREET
ADDRESS of CHARITABLE ORGANIZATION
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FROM and TO DATES
(Month/Day/Year)
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17.
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IS THE REGISTRANT LICENSED BY, REGISTERED WITH OR HAVE A PERMIT FROM
ANY OTHER GOVERNMENTAL AGENCY FOR THE PURPOSE OF PROVIDING FUNDRAISING
COUNSEL FOR CHARITABLE ORGANIZATIONS YES NO
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IF "YES" LIST THE FOLLOWING INFORMATION:
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NAME and ADDRESS of GOVERNMENTAL AGENCY
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DATE of AUTHORIZATION
(Month/Day/Year)
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18.
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HAS THE REGISTRANT EVER HAD ANY LICENSE, REGISTRATION OR PERMIT
DENIED, CANCELED OR REVOKED, OR IS ANY SUCH ACTION PENDING? YES NO
IF "YES" ATTACH A SCHEDULE INDICATING NAME and ADDRESS of
GOVERNMENTAL AGENCY, NATURE of ACTION, DATE of ACTION
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19.
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HAS ANY GOVERNMENTAL ACTION, OTHER THAN LISTED IN 20 ABOVE, BEEN TAKEN
AGAINST THE BUSINESS OR ANY OF ITS PRINCIPAL PARTIES, EMPLOYEES, OFFICERS,
DIRECTORS, EXECUTIVE PERSONNEL, OWNERS OF TEN PERCENT OR MORE OF THE CAPITAL
STOCK OR THEIR RELATIONS IN CONNECTION WITH ANY FUNDRAISING ACTIVITY? YES
NO
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IF "YES" ATTACH A SCHEDULE INDICATING NAME
and ADDRESS of GOVERNMENTAL AGENCY, AGAINST WHOM ACTION WAS TAKEN, NATURE of
ACTION, DATE of ACTION.
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20.
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HAS ANY OF THE FIRM'S PRINCIPAL PARTIES, EMPLOYEES, OFFICERS,
DIRECTORS, EXECUTIVE PERSONNEL, OWNERS OF TEN PERCENT OR MORE OF THE CAPITAL
STOCK OR THEIR RELATIONS EVER BEEN CONVICTED OF A MISDEMEANOR INVOLVING THE
MISAPPROPRIATION OR MISUSE OF MONEY OF ANOTHER, OR OF ANY FELONY? YES
NO
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IF "YES" ATTACH A SCHEDULE INDICATING NAME
and ADDRESS of COURT, WHO WAS CONVICTED, NATURE of OFFENSE, DATE of
CONVICTION.
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NOTE: VERIFICATION MUST BE BY THE CORPORATE
PRESIDENT, A GENERAL PARTNER OR THE SOLE PROPRIETOR.
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STATE OF
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SS
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AFFIDAVIT
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COUNTY OF
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I,
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, under penalty of perjury and being sworn on oath
state
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that
I am (strike out) the CORPORATE PRESIDENT, a GENERAL PARTNER or the SOLE
PROPRIETOR of the registrant professional fund raiser.
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(Name of PFC)
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, that I have read the foregoing registration
statement and personally
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know
the contents thereof to be true, and such is stated and filed with the Illinois
Attorney General for the purpose of having the people of the State of Illinois
rely thereupon. I hereby further authorize and agree to submit myself and the
registrant hereby to the jurisdiction of the State of Illinois.
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Subscribed and sworn to before me
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this
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day of
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,
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19
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(Signature)
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NOTARY PUBLIC
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(Source: Added
at 24 Ill. Reg. 14684, effective September 21, 2000)
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