North Carolina Department of the Secretary of State
Charitable Solicitation Licensing
Fundraising Disclosure Form
for charitable or sponsor organizations
CSL Contact Information:
Agency Internet Site: www.sosnc.gov Electronic Mail: csl@sosnc.gov
Telephone: (919) 814-5400 - Toll free for NC residents: 1-888-830-4989
Facsimile: (919) 807-2220
Mailing Address: P.O. Box 29622, Raleigh, NC 27626-0622
Fund-raising Disclosure Form
for charitable or sponsor organizations
Form Revision: September 24, 2020
Effective Date: November 19, 2004
Page 1 of 1
Form ______ of _______ filed with this application
1. Applicant Name:
2. Contractor Name:
3. Contractor Street Address:
4. Contractor Telephone Number:
5. Contractor Type: Coventurer | Fund-raising Consultant Solicitor
6. Contract Signing/Execution Date:
7. Contract services Begin Date:
8. Contract services End Date:
9. Is this a continuing or multiyear contract? YES | NO
10. Are North Carolina residents solicited for contributions as
a direct or indirect result of this contract? YES | NO
11. Does contract contain salary, rate, or fee terms? YES | NO
If YES, state terms and conditions below:
12. Does contract contain bonus terms? YES | NO
If YES, state terms and conditions below:
13. Does contract contain commission terms? YES | NO
If YES, state terms and conditions below:
14. Does contract contain expenses terms? YES | NO
If YES, state terms and conditions below:
15. Does contract contain other compensation terms? YES | NO
If YES, state terms and conditions below:
16. Amount of funds received resulting from contract since your last license application filing:
(For initial applicants: amount of funds received within past fiscal year or past 12 months):
Answer either or both line items: Gross Amount Received: $___________________________
Net Amount Received: $___________________________
