Fillable LICENSE APPLICATION FOR CHARITABLE SOLICITATION MUNICIPAL CODE SECTION (City of South Bend)

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LICENSE APPLICATION FOR CHARITABLE SOLICITATION MUNICIPAL CODE SECTION (City of South Bend)

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The LICENSE APPLICATION FOR CHARITABLE SOLICITATION MUNICIPAL CODE SECTION (City of South Bend) form is 6 pages long and contains:

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For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – CHARITABLE SOLICITATION
MUNICIPAL CODE SECTION - 4-55
DEFINITION:
Charitable solicitation includes the request for financial assistance in connection with
philanthropic purposes as well as the sale or attempted sale of items or services in connection
with philanthropic purposes or organizations.
NOTE:
See South Bend Municipal Code for solicitations not requiring permit.
GENERAL INSTRUCTIONS:
1. Print legibly and complete all sections to ensure efficient processing.
2. Assemble all required information and materials before filing application.
3. Thoroughly review all applicable Municipal Code Sections listed above.
4. Licenses expire January 31.
5. Add 10% to license fee for renewal after January 31.
6. Include $5.00 license application fee payable to City of South Bend.
7. License fee payable to City of South Bend due at issuance - $45.00.
REQUIRED INFORMATION AND MATERIALS:
1. Applicant, organization, purpose, amount, manner and disposition information.
2. Statement disclaiming City endorsement.
3. Statement of charitable purpose and percent of funds raised to be used thus.
APPLICATION PROCESS:
1. Submit Application with $5.00 Processing Fee at least 30 days before desired permit date.
2. Controller Denies or Approves License.
3. License issued on payment of fee.
4. License Holder may solicit only with permit in hand, complying with receipt requirements.
5. Submit report and financial statement to Controller within sixty (60) days after solicitation
complete.
1
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – CHARITABLE SOLICITATION
MUNICIPAL CODE SECTION - 4-55
I. APPLICATION TYPE Check One: New Renewal
II. ORGANIZATION INFORMATION
A. Name of Applying Organization:
B. Organization Address:
City: State: Zip:
C. Mailing Address (if differs):
City: State: Zip:
D. Organization Telephone Number:
E. Organization Fax Number:
F. Organization E-Mail Address:
G. If Organization is a Corporation or Partnership, list names and addresses of all principal
officers. If not, skip to Section III.
(Attach additional sheets if necessary)
Name #1:
Title:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
Business Telephone Number:
Home Telephone Number:
For Office Use Only
Application Filed Police Department
Application Fee Paid Controller Approval
Sent to Dept. License Fee Paid
License Number
Not Approved
Reason
2
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – CHARITABLE SOLICITATION
MUNICIPAL CODE SECTION - 4-55
II. ORGANIZATION INFORMATION (Continued)
G. Principal Corporate Officers or Partners (Continued)
Name #2:
Title:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
Business Telephone Number:
Home Telephone Number:
Name #3:
Title:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
Business Telephone Number:
Home Telephone Number:
III. CHARITABLE SOLICITATION INFORMATION
A. Solicitation Period will begin on: / / and end on / /
B. Describe the purpose for which the Solicitation is to be made:
C. Outline the method(s) of solicitation to be used:
D. Describe the kind and extent of charitable work being done by the organization:
3
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – CHARITABLE SOLICITATION
MUNICIPAL CODE SECTION - 4-55
III. CHARITABLE SOLICITATION INFORMATION (Continued)
E. Will a professional fund raising consultant or professional solicitor be used?
NO (Skip to Section IV)
YES (State the name and address of the professional consultant/solicitor)
1. Professional’s name:
2. Business Address:
City: State: Zip:
IV. FINANCIAL INFORMATION
A. Estimated total amount of funds to be raised:
B. Expenses:
1. Salaries/Commissions:
2. Merchandise/Entertainment:
3. Promoter’s Fees:
4. Printing:
5. Rent:
6. Office Expenses:
7. Other:
Total Expenses:
C. Estimated percentage of solicited funds to be used directly for charitable work:
D. Estimated percentage of solicited funds that will be retained in the City:
E. Name(s) and address(s) of organization(s) receiving disbursements from the proposed
solicitation:
N
ame Address
4
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – CHARITABLE SOLICITATION
MUNICIPAL CODE SECTION - 4-55
V. PERSONAL DATA
Indicate the name(s) and address(s) of organization(s) having overall responsibility for the solicitation:
APPLICANT 1
A. Applicant's Legal Name:
B. Residential Address:
City: State: Zip:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Number:
F. E-Mail Address:
G. Position with business:
H. Date of birth:
I. Gender:
J. Social Security Number:
K. Race:
APPLICANT 2
A. Applicant's Legal Name:
B. Residential Address:
City: State: Zip:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Number:
F. E-Mail Address:
G. Position with business:
H. Date of birth:
I. Gender:
J. Social Security Number:
K. Race:
APPLICANT 3
A. Applicant's Legal Name:
B. Residential Address:
City: State: Zip:
5
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR – CHARITABLE SOLICITATION
MUNICIPAL CODE SECTION - 4-55
V. PERSONAL DATA (Continued)
APPLICANT 3 (Continued)
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Number:
F. E-Mail Address:
G. Position with business:
H. Date of birth:
I. Gender:
J. Social Security Number:
K. Race:
VI. IF PROFESSIONAL SOLICITORS ARE USED, INCLUDE COPIES OF
A. State of Indiana Consultant/Solicitor Registration.
B. Contract between Consultant/Solicitor and Applicant.
VII. IF APPLICANT IS A CORPORATION, INCLUDE COPY OF
A. Resolution authorizing solicitation for which application is filed.
VIII. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
IX. AFFIRMATION
I, hereby, certify and affirm that all of the information I have given in this application is true and
accurate to the best of my knowledge. I further certify that I have in no way attempted to
mislead the City in this application by omitting facts known to me. I understand that the
completed application must be filed no less than thirty (30) days before the proposed
beginning date of the solicitation. I have read and understand the regulations of the Charitable
Solicitations license found in the City of South Bend Municipal Code, Section 4-55. Finally, I
understand that, if registration and a permit are granted, it will not be used or represented in
any way or manner, that such is an endorsement by the City of South Bend or by any
Department or Officer thereof.
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LICENSE APPLICATION FOR CHARITABLE SOLICITATION MUNICIPAL CODE SECTION (City of South Bend)

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Completed 16 July 2020

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