Oregon Department Of Justice Fund Raising Firm Report
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1
2Official Use Only
Oregon Department of Justice Fund-Raising Firm
Solicitation Campaign Financial Report PF-12
(Instructions on reverse)
1. Name of professional/commercial fund-raising firm:
OR Registration #:
Ongoing campaign?
yes
no
2. Name of nonprofit beneficiary:
Campaign Start Date:
Campaign End Date:
/
/
/
/
3. Financial Report:
A. Amount Paid to Beneficiary.........................................................................$____________
Cost of Goods or Services Sold,
(if applicable)
Itemize:
Item Cost:
$_________
$_________
$_________
$_________
+
B. Total Cost of Goods or Services Sold..........................................................$____________
Direct Costs of Solicitation
Itemize:
Item Cost:
$_________
$_________
$_________
$_________
+
C. Total Direct Costs of Solicitation ................................................................$____________
+
D. Amount Retained by Fund-Raising Firm (
.......$____________
management salaries and profit)
=
E. Gross Campaign Revenue ...........................................................................$____________
NOTE: The total of items A, B, C, and D must equal the amount in item E, Gross Campaign Revenue
I hereby certify that the foregoing information is true and correct to the best of my knowledge and belief.
______________________________________________________
State of __________________
Affiant for Fund-Raising Firm
County of ________________
Subscribed and sworn to before me on _______________, 20_____
By ____________________________________________________
(print name of affiant)
___________________________________________
(signature of notarial officer)
Notary Public - State of _______________________
I hereby certify that the foregoing information is true and correct to the best of my knowledge and belief.
_______________________________________________________
State of __________________
Affiant for Nonprofit Beneficiary
County of ________________
Subscribed and sworn to before me on ________________, 20 _____
By _____________________________________________________
(print name of affiant)
___________________________________________
(signature of notarial officer)
Notary Public - State of _______________________
Rev 11/25/03
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