FDACS-10110 Rev. 01/15
Page II of II
List the representatives as directed with complete street addresses and telephone numbers for each. All documents and
attachments submitted with this application are subject to public records review pursuant to Chapter 119, F.S. However,
exemptions apply to certain employees. If you qualify under these exemptions, you can request that certain information be
redacted from the public records available through the department. Exemptions may apply to:
Current or former law enforcement officers and their families;
Current or former judges and their families;
Current or former prosecutors and their families;
Current or former firefighters and their families;
Current or former human resources managers and their families; and
Current or former code enforcement officers and their families.
This is not a comprehensive list. For a complete list, see Section 119.071(4), F.S. If you qualify for one of the public records
exemptions and wish to have your information exempted from public review, please check the appropriate box.
Briefly explain the purpose for which your organization was created. It is best to summarize this information in your own words.
Briefly explain the purpose for which contributions will be used.
Indicate by checking the appropriate box on the application which type of financial report you are filing. Only newly established
organizations with no financial history may submit a budget for the current year. The financial statement on page 3 may be
used to prepare a budget. ONLY THE FOLLOWING WILL BE ACCEPTED FOR ALL OTHER ORGANIZATIONS:
IRS form 990 with all attached schedules
IRS form 990-EZ and Schedule O
the financial statement on this form.
We cannot accept the 990-PF, 990-N, E-Postcard or 990-T or any other type of tax return. We cannot accept quarterly
reports or audited reports without the form 990. You may submit these types of financial documents in addition to the required
financial information, but they cannot be a substitute for one of the three acceptable financial reports mentioned above. If
sending multiple financial forms, they must be consolidated prior to submission on the department’s financial report.
Provide the name and contact information for the person responsible for completing the application.
SEND COMPLETED APPLICATION TO:
Solicitation of Contributions
2005 Apalachee Parkway
Tallahassee, FL 32399-6500
IMPORTANT: Every charitable organization or sponsor that is required to register under s. 496.405, F.S., or is exempt
under s. 496.406(1)(d), F.S., shall conspicuously display the following statement on every solicitation, confirmation, receipt,
or reminder of a contribution: “A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE
OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE WITHIN THE STATE.
REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.” The
statement must include a toll-free number and website for the division which can be used to obtain the registration
information. When the solicitation consists of more than one piece, the statement must be displayed prominently in the
solicitation materials. If the solicitation occurs on a website, the statement must be conspicuously displayed on any
webpage that identifies a mailing address where contributions are to be sent, identifies a telephone number to call to
process contributions, or provides for online processing of contributions. The toll-free number of the department is 1-800-
HELP-FLA (435-7352) or (850) 410-3800. The department’s website is www.FDACS.gov.