Charitable Organization Disclosure Form
Registrants must provide a copy of the contract between the registrant and each charitable organization that receives funds
solicited by the registrant in or from Iowa during this registration period.
If a registrant solicits funds for more charitable organizations than space allows, additional charities must be reported on
supplemental Charitable Organization Disclosure Forms.
Name of Professional Fundraiser:
Name of Charitable Organization:
Solicitation Dates:
Begin Date:
End Date:
Soliciting will be conducted by:
Electronic Media (TV, radio)
(check all that apply)
Direct Mail
Print Media (newspapers, magazines)
If persons will be contacted by telephone and mail, how will the initial contact be made:
Telephone Mail
Are contributions made to the charitable organization tax deductible?
Telephone Mail
If soliciting will be conducted by telephone, and details regarding the call centers are not included in the submitted contract,
provide the following information for each location from which the calls will be made.
Room 1
City State Zip Code
City State Zip Code
City State
Zip Code
All telephone numbers which solicitations are made:
Room 2
All telephone numbers which solicitations are made:
Room 3
All telephone numbers which solicitations are made:
Name(s) of manager(s) and/or supervisor(s) of the room:
Financial Information
Provide the following financial information for the past one (1) year period. If fundraising has not yet been conducted for a one
year period, specify the date range for the reported data.
Start date (mm/dd/yyyy):
End date (mm/dd/yyyy):
Total amount raised by the registrant, in any manner, on behalf of the charitable organization:
Total given to (or retained by) the charitable organization:
Total not given to charitable organization but expended by registrant on behalf of the charitable organization:
Total amount billed to the charitable organization by the professional fundraiser:
Signature and Notices
If additional contracts are entered into after the filing of this Charitable Organization Disclosure Form, copies of the contracts
must be submitted to tis office at that time.
All information and documentation provided as of this part disclosure form, including this form are public records and all or
some may be open to public inspection pursuant to the Iowa public records law, Iowa Code chapter 22, and the Iowa Attorney
General’s Administrative Rules relating to public records, 61 1AC chapter 2.
I hereby certify, under penalty of perjury and pursuant to the laws of the state of Iowa, that I am authorized to sign this
Charitable Organization Disclosure Form and that the information provided is true and complete to the best of my knowledge.
This completed form, copies of all contracts between the registrant and a charitable organization should be sent to the Iowa
Attorney General’s Office at the address below.
Iowa Attorney General
Consumer Protection Division
1305 E. Walnut Street
Des Moines, IA 50319
P: 515.281.5926
Printed Name: