Professional Fund Raiser Registration Statement w-Instructions {PFR-01}

Form PFR-01 Revised 1/19 Indicate by an "X" PROFESSIONAL FUND RAISER REGISTRATION STATEMENT For Fiscal Year July 1, Through June 30, KWAME RAOUL ATTORNEY GENERAL 1. A NEW REGISTRATION RE-REGISTRATION CHANGE ADDITION AS OF // 2. INDIVIDUAL PARTNERSHIP or CORPORATION Attach: Partnership Agreement or Articles of Incorporation 3. NAME OF CHIEF MANAGEMENT PERSON(S) TITLE (Attach Schedules as needed) TITLE 4. NAME & ADDRESS OF ILLINOIS REGISTERED AGENT: (Address must be a street address for service) Name: Address: 5. LIST ALL PRINCIPAL PARTIES, OFFICERS, DIRECTORS, EXECUTIVE PERSONNEL, AND OWNERS OF TEN PERCENT OR MORE OF THE CAPITAL STOCK (ATTACH SCHEDULE as needed INDICATING NAME, STREET ADDRESS, TITLE, % OF INTEREST for each person listed). Name Title Name Title Address Address Name Title Name Title Address Address 02- CITY, STATE, ZIP CODE American LegalNet, Inc. www.FormsWorkFlow.com 6. WERE ALL PROFESSIONAL SOLICITORS FURNISHED A 1099 OR W2 LAST YEAR? Yes No If NO, EXPLAIN IN DETAIL. COMPLETE AND ATTACH FORM PS-01. 7. HAVE ANY OF THE FIRM'S PRINCIPAL PARTIES, EMPLOYEES, OFFICERS, DIRECTORS, EXECUTIVE PERSONNEL, OWNERS OF TEN PERCENT OR MORE OF THE CAPITAL STOCK OR THEIR RELATIONS EVER BEEN CONVICTED OF A MISDEMEANOR INVOLVING THE MISAPPROPRIATION OR MISUSE OF MONEY OF ANOTHER, OR OF ANY FELONY? Yes No IF "YES", INDICATE WHO WAS CONVICTED. THE NATURE of OFFENSE, DATE of CONVICTION, and NAME and ADDRESS of COURT. 8. LIST THE INTEREST OF ALL PRINCIPAL PARTIES, OFFICERS, DIRECTORS, EXECUTIVE PERSONNEL, OWNERS OF REGISTRANT AND THEIR FAMILY MEMBERS IN ANY OTHER FIRMS PROVIDING GOODS OR SERVICES USED IN FUND RAISING. NATURE OF BUSINESS NAME OF PARTY % INTEREST NAME & STREET ADDRESS OF BUSINESS 9. COMPLETE & ATTACH FORM PFR-06 FOR ALL CHARITIES HAVING CONTRACTS WITH PFR. ATTACH THE FOLLOWING AS A PART OF REGISTRATION AND INDICATE BY AN "X" THOSE ATTACHED: Partnership Agreement or Articles of Incorporation of Professional Fund Raiser (PFR). Certificate of Authority to Transact Business in Illinois (Out of state PFRs only). Form CS-6 (PFR Bond). Form PFR-06 (List of Charities for fund Raising services are to be provided.). Form PS-01 (For all Solicitors employed by PFR). List all business locations, other than above, used for fundraising. (attach a schedule indicating street address, city, state). All schedules and for any of the above questions. Copies of all Fund Raising Contracts Charities including Amendments, and NOTE: VERIFICATION MUST BE BY THE CORPORATE PRESIDENT, A GENERAL PARTNER OR THE SOLE PROPRIETOR. STATE OF ) COUNTY OF ) - - ss AFFIDAVIT ke out) the CORPORATE PRESIDENT, a GENERAL PARTNER or the SOLE PROPRIETOR of the registrant professional fund raiser. I have read the forgoing registration statement and personally the contents thereof to be true, and each and every attachment, attached form and attached schedule, the content thereof as stated by me and filed by me the Illinois Attorney General for the purpose of having the people of the State of Illinois rely thereupon. I hereby further authorize and agree to submit myself and the registrant hereby to the jurisdiction of the State of Illinois. Subscribed This day of , 20 Notary Public (Signature) (Print Name & Title) Attach as many copies of this form and all schedules needed to complete your registration. Send completed registration to: Attorney General's Office, Charitable Trust Bureau, 100 West Randolph, 11th Floor, Chicago, Illinois 60601 American LegalNet, Inc. www.FormsWorkFlow.com