Raiser Statement Inspection Form – Fill Out and Use

Form CHAR037	Professional Fund Raiser Interim /Closing Statem ent
	New York State Department of Law (Office of the Attorney General)			Open to Public
		Charities Bureau
		The Capitol		Inspection
Article 7-A of the Executive Law		Albany, NY 12224
		http://www.CharitiesNYS.com

Part A - Identification of Contracting Professional Fund Raiser(s)

___ ___ - ___ ___ - ___ ___

___ ___ - ___ ___ - ___ ___

Part B - Identification of Contracting Charitable Organization(s)

Part C - Statement Information

4.Original Filing ID of Corresponding Contract (Refer to this office’s Notice of Receipt of Contract sent to the PFR upon the filing of the original corresponding contract.)

5.	Type of Statement:	G Interim Statement		G Closing Statement
6.	Were services provided at any time other than during the Contract Period (C1) or, for multi-year contracts, the Contract Year (C2)? G Yes G No

Part D - Certification

We, an authorized representative of the Professional Fund Raiser and an authorized representative of the Charitable Organization, certify under the penalties for perjury, that we reviewed this Interim/Closing Statement, and to the best of our knowledge and belief, it is true, correct and complete in accordance with the laws of the State of New York applicable to this statement.

1. Professional Fund Raiser

Page 1 of 3

Form CHAR037 (2010)

Part E - Activity and Conduct

1. Specify the methods of solicitation (Column A) and the types of contributions solicited (Column B). (Check all that apply.)

COLUMN A		COLUMN B
Telemarketing	G	Monetary Contributions	G
Direct Mail	G	Donation of New or Used Goods	G
Door to Door	G	Tickets to a Dinner/Gala/Other Special Event	G
Electronic Media (TV, Radio)	G	Ads in a Publication/Magazine	G
Print Media	G	Purchase of a Product	G
Internet	G	Grants	G
Email	G	Volunteers	G
Other (please describe):	G	Other (please describe):	G

2.Did this campaign involve the solicitation of persons in New York State only, the solicitation of persons in New York State and other states or the solicitation of persons only in other states?

New York State Only. . . . . . . . . . . . . . . . . . . . . .G (Complete only Columns I and II in Part F - Financial Report (page 3))

New York State and Other States . . . . . . . . . . . G. (Complete all Columns in Part F - Financial Report (page 3))

Other States Only.. . . . . . . . . . . . . . . . . . . . . . . G. (Do not complete Part F - Financial Report (page 3), but provide below an explanation as to why the corresponding contract was filed with the Charities Bureau.)

Explanation:

3.Within five days of receipt, were all contributions received from solicitation activity under this contract deposited in a bank account under the exclusive control of the charitable organization listed above?.................G Yes* G No* G Not Applicable (PFR had no access to contributions)

*If “Yes” or “No”, complete account information below:

Bank Name:

Bank Address:

Account Name:

4. Did the professional fund raiser subcontract any contractual services to an third party during the specified Contract Period or, if a multi-year contract, the Contract Year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G Yes* G No

*If “Yes,” provide each subcontractor’s name, NY PFR ID#, address and telephone number.

5. Has the professional fund raiser provided all contractual services and has the charitable organization received all contractual monetary payments

required by the contract?

G Yes G No*

*If “No,” provide an explanation:

Page 2 of 3

Form CHAR037 (2010)

Part F - Financial Report

1.	GROSS REVENUE
a.	Monetary Contributions Solicited By PFR						$				$
b.	Advertisement Sales						$				$
c.	Entertainment Sales/Admission Charges						$				$
d.	Other Product Sales (Identify Product:					)	$				$
e.	Monetary Contributions Solicited By PFR Recruited Volunteers						$				$
f.	Other Revenue Source (Describe:					)	$				$
g.	Other Revenue Source (Describe:					)	$				$
h.	Other Revenue Source (Describe:					)	$				$
i.	. . . .TOTAL GROSS REVENUE (Add lines #1a through #1h)							$				$
2.	EXPENSES
a.	PFR’s Remuneration/Fee						$				$
b.	Salaries & Benefits For Professional Solicitors,
	Office Manager, Other PFR Employees						$				$
c.	Subcontractor’s Fee (Identify Subcontractor(s) in Part E4)						$				$
d.	Permits, Licenses, Registration Fees, Etc						$				$
e.	Office Rent, Office Utilities, Office Insurance						$				$
f.	Office Supplies, Other Office Expenses						$				$
g.	Computer/Data Processing Service Fees						$				$
h.	Telephone						$				$
i.	Printing						$				$
j.	Advertising						$				$
k.	List Rentals						$				$
l.	Postage & Shipping						$				$
m.	Show/Event Fee						$				$
n.	Show/Event Facilities Rental Fee & Insurance						$				$
o.	Cost of Merchandise For Resale						$				$
p.	Other Expense (Describe:					)	$				$
q.	Other Expense (Describe:					)	$				$
r.	Other Expense (Describe:					)	$				$
s.	Other Expense (Describe:					)	$				$
t.	. . . . . . . . .TOTAL EXPENSES (Add lines #2a through #2s)							$(	)			$(	)
3.	NET AMOUNT RETAINED BY THE CHARITY
	(Subtract line #2t from line #1i)							$				$
4.	AD D ITIO N AL GU AR AN TEED M O N IES PAID TO TH E C H AR ITY							$				$
5.	MISCELLANEOUS
a.	Uncollected Pledges as of the Date of this Report						$				$
b.	In-Kind (Non-Cash) Donations (Describe:					)	$				$
c.	Professional Fund Raiser’s Profit/Loss (Optional)
	(not the same as line #2a)						$				$

Page 3 of 3

Form CHAR037 (2010)

New York State Departm ent of Law (Office of the Attorney General) Charities Bureau

Instructions for Form CHAR037 (Professional Fund Raiser Interim/Closing Statement)

and Summary of Filing Requirements for Professional Fund Raiser Interim/Closing Statements

http://www.CharitiesNYS.com

Important Notice: These Instructions and Summary are intended to provide assistance in completing Form CHAR037. Also included is information on the filing requirements relating to Professional Fund Raiser Interim/Closing Statements. For additional information on registration and filing requirements pursuant to the Executive Law, registrants and potential registrants are encouraged to familiarize themselves with §171-a through §177 of Article 7-A of the Executive Law and NYCRR Title 13, Chapter V, Parts 90 - 99.

I.General Instructions in Completing Form CHAR037

A.Type or print in ink the responses to all items on pages 1 - 3 of Form CHAR037. Enter "NA" for any item that is not applicable.

B.In all instances "PFR Representative" or an “authorized representative of the Professional Fund Raiser” shall mean an owner, partner, director, officer, manager or key employee of the contracting PFR.

C.In all instances "Charity Representative" or an “authorized representative of the Charitable Organization” shall mean an officer, director or key employee of the contracting Charity.

D.The Financial Report (Part F, page 3) must report, on an accrual basis, all revenues received by or on behalf of the charitable organization(s) and all expenses incurred by the professional fund raiser(s) and the charitable organization(s) as a result of services provided during the specified contract period or contract year (if a multi-year contract). Include additional itemized income sources and itemized expenses on a separate attachment, using the same schedule format as the Financial Report.

II.PFR and Charity Certification

An authorized representative of the Professional Fund Raiser and an authorized representative of the Charitable Organization must certify to all statements made in Form CHAR037. The signatures on Form CHAR037, Part D must be accompanied by each signatory’s printed name, title and the date signed.

III.Amendments to Form CHAR037

A Professional Fund Raiser should file an amended CHAR037 whenever there is a material change to the information provided on a previously filed interim/closing statement, including changes in revenue and expense figures. All Parts (A - F) on an amended Form CHAR037 must be completed. Additionally, the word “AMENDED” must be placed at the top of page 1, Form CHAR037.

IV.	Form CHAR037 Due Dates
	A closing statement is due within 90 days after the termination of a contract. For a contract whose term is longer than one year,
	an interim statement must be filed within 15 months of the execution of the contract and annually thereafter.

V.Mailing Instructions

All completed Form CHAR037 should be mailed to the following address:

New York State Department of Law (Office of the Attorney General)

Charities Bureau

The Capitol

Albany, NY 12224

VI.	Additional Charities Bureau Contact Information
	Telephone:	(518) 486-9797
	E-mail:	Charities.Fundraising@ag.ny.gov

-i-	Instructions for Form CHAR037/CHAR037 Summary (2010)