Form PFR-02

PROFESSIONAL FUND RAISER ANNUAL FINANCIAL REPORT

JIM RYAN

ATTORNEY GENERAL

THIS MUST BE FILED BY

FILE AT:  Office of the Attorney General, Charitable Trust and Solicitations Bureau, 100 West Randolph Street, Chicago, Illinois 60601

GENERAL INSTRUCTIONS (FURTHER INSTRUCTIONS AT END OF FORM)

PLEASE TYPE OR PRINT IN BLACK INK

A.

RESPOND TO ALL ITEMS ON THIS FORM.

B.

CHANGES OF OR ADDITIONS TO THE INFORMATION IN THIS STATEMENT MUST BE SUBMITTED IN THIS FORMAT.

C.

ANNUAL REPORT (CHECK ONE):

PREPARED ON ACCRUAL BASIS 

PREPARED ON A CASH BASIS 

OR PREPARED BY ANOTHER METHOD 

IF PREPARED BY ANOTHER METHOD EXPLAIN:

LEGAL NAME

REGISTERED FOR FISCAL YEAR

MAIL ADDRESS

ENDED JUNE 30,

AS

CITY

PFR# 02-

STATE, ZIP CODE

FEDERAL ID NUMBER

PHONE NUMBER

(             )

REPORT IS FOR PERIOD BEGINNING JANUARY 1,

AND ENDING

CHARITIES FOR WHOM FUNDS WERE RAISED

(A)

AMOUNT TO

CHARITY

(B)

SOLICITATION

EXPENSES

(C))

TOTAL AMOUNT RAISED

(D)

% = A/C

TOTAL FOR ALL CHARITABLE FUNDRAISING BY PFR:

TOTAL NUMBER OF CHARITIES BEING REPORTED

Note:  Verification must be by the Corporate President, a General Partner or the Sole Proprietor

STATE OF

}

SS

AFFIDAVIT

COUNTY OF

I,

, under penalty of perjury and being sworn on oath that I am (circle one) the

corporate president, a general partner or the sole proprietor of the registered professional fundraiser.

(Name of PFR)________________________________

, have read this annual report including all attachments and personally

know the contents thereof to be true, and such is stated herein 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 be jurisdiction of the State of Illinois.

Subscribed and sworn to

before me, this

(Signature)

day of

19

.

NOTARY PUBLIC