Free Chchf - West Virginia

STATE OF WEST VIRGINIA

Registration Statement of Professional Fund Raiser or Fund-Raising Counsel
Send Registration Statement, fee, bond and supporting documents to: Secretary of State State Capitol Room 157-K Charleston, WV 25305 Phone: (304) 558-6000 Fax: (304) 558-0900

Instructions
raising counsel or professional solicitor unless he or she is first registered and bonded with the Secretary of State. 1. 2. 3. 4. Please complete all items which are applicable to your organization. The registration must be signed and notarized. All professional fund raisers and fund-raising counsels are required to send a registration fee of $100. Checks should be made payable to the Secretary of State. All professional fund raisers and fund-raising counsels are required to file a $10,000 bond on the form provided with this registration which must be approved by the Attorney Generals office. Every written contract or agreement between professional fund-raising counsels or solicitors and charitable organizations must be filed with the Secretary of State within ten days after the parties have entered into such an agreement (§29-19-7). An extension of time to file an annual registration or report must be requested in writing before the registration expiration date. For good cause, the Secretary of State will extend the due date for a period not to exceed 90 days. [§20-19-5 (e)]. Organizations failing to file a registration by the original or extended due date will be required to pay an additional late fee of $25 for each month or part of a month the filing is late [§29-19-5(f)]. Copies of all scripts and solicitation materials used to solicit funds in West Virginia must be submitted to the Secretary of State.

West Virginia Code § 29-19-9 provides that no person may act as a professional fund-

5.

6. 7.

REGISTRATION STATEMENT
New Registration Renewal Professional Fund Raiser Professional Fund-Raising Counsel 1. 2. 3. 4. 5. 6. Date

Name of Business: Street Address: Mailing Address: City: State: Phone: Fax: Principal West Virginia Address, if different from above: Phone:

Zip:

7. 8. 9. 10.

Type of Business Entity:

Sole Proprietorship Corporation Date and Place business entity was organized or incorporated: List all DBAs used by the business entity:

Partnership Other

Names and addresses of all individuals, partners, officers and principal salaried staff:

11.

Names and addresses of all employees operating in or soliciting in West Virginia: (Attach list if necessary.)

12.

Names and addresses of all sub-contractors responsible for soliciting in West Virginia:

13.

Give location of all telemarketing operations in West Virginia:

14.

List all mailing addresses, including Post Office Boxes, to be employed in the solicitation of funds in West Virginia.

15.

List names and addresses of all charitable organizations with which the organization has contracts to act as professional fund raiser or fund-raising counsel, in this state:
(Give name and full address of each Charitable Organization)

1. 2. 3. 4. 5. 16. Terms of Remuneration Per Contract: 1. 2. 3. 4. 5. Are all current contracts with charitable organizations on file in this office as required by law? Yes No List the names and addresses of professional solicitors employed by the organization, in West Virginia and the terms of remuneration. 1. 2. 3. 19. Is the organization licensed by, registered with, or have a permit from any other governmental agency for the purpose of soliciting funds for charitable organizations in any state? Yes No If yes, give the following information: Names: 1. 2. 3. City: State:

17.

18.

Date of Authorization: Month: 1. 2. 3. 20.

Day:

Year:

Has the organization had any license, registration or permit denied, cancelled or revoked in any state? Yes No If yes, give the following information: Name and address of the authority taking action and the nature and date of the disciplinary action:

21.

Has any official disciplinary action, other than the actions listed in Item 20, and including court action, been taken against the organization of any members, employees, officers or directors in any state? Yes No If yes, give the following information: Name and address of government agency and the nature and date of the action:

I hereby certify under oath that all answers and statements given by me are true and correct without reservation of any kind. It is understood that all facts in this application are open to thorough investigation. (Date) State of County of Subscribed and sworn before me this My Commission Expires day of , . Notary Public PRINT OR SAVE THIS COPY, THEN CLICK HERE TO RESET. (Year) (Signature of Applicant) (Title)

STATE OF WEST VIRGINIA PROFESSIONAL FUND-RAISING COUNSEL=S AND/OR PROFESSIONAL SOLICITOR=S BOND
SECRETARY OF STATE 1900 KANAWHA BLVD., SUITE 157-K CHARLESTON, WV 25305-0770 BOND NUMBER_____________________________ KNOW ALL MEN BY THESE PRESENTS: THAT (Name of Individual, Partnership or Corporation) ___________________________________________________ of (Address) ________________________________________________________________________________________ as Principal, and ___________________________,of(Address)_______________________________________________ _______________________________________, as Surety. Are held and firmly bound unto the State of West Virginia for the use of the Secretary of State, and to any person who may have a cause of action against the Principal for any losses resulting from malfeasance, nonfeasance or misfeasance, in the conduct of solicitation activities, in the sum of TEN THOUSAND DOLLARS ($10,000), lawful money for use of the Secretary of State, and to any person who may have a cause of action against the Principal for any such losses, as their interests may appear, not exceeding in the aggregate the said sum of TEN THOUSAND DOLLARS ($10,000) for which payment will and truly be made we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally by these presents. WHEREAS, the above bound Principal has applied to the Secretary of State of the State of West Virginia for registration as a Professional Fund-Raising Counsel or Professional Solicitor for a charitable organization pursuant to West Virginia Code ' 29-19-9, as amended. NOW, the condition of this obligation is such, That if the Secretary of State shall register the above bound Principal as such Professional Fund-Raising Counsel or Professional Solicitor and said Principal shall faithfully and honestly act as such Professional FundRaising Counsel or Professional Solicitor in accordance with law, and fully complies with the provisions of Chapter 29, Article 19 of the West Virginia Code, as amended; and if the Principal shall fully indemnify and save harmless from loss the State of West Virginia and any person who may have a cause of action against the Principal for any losses resulting from malfeasance, nonfeasance or misfeasance, in the conduct of solicitation activities, then this obligation shall be void; otherwise it will remain in full force and effect. This bond is to cover all claims arising on account of the registration of the Principal and his acting in performance thereof. This bond shall be effective from the_____ day of _____, 20_____. Executed this _____day of ________________________________, (Year) _______. ____________________________________(Corporate Seal) Principal Signature Title: _____________________________ President or Vice- President _______________________________(Corporate Seal) Surety Company _________________________________ Authorized Signature - Surety Company
Attach Power of Attorney with raised seal, current as of the execution date.

Approved as to Form and Sufficiency of Execution: By ____________________________________________________ Assistant Attorney General

ACKNOWLEDGMENT BY PRINCIPAL IF INDIVIDUAL OR PARTNERSHIP STATE OF _________________ COUNTY OF ________________, To-wit: I, _______________________________________________________, a Notary Public in and for the county and state aforesaid do hereby certify that ___________________________________________________________, whose name is signed to the foregoing writing, has this day acknowledged the same before me. Given under my hand this ____day of ______________________, (Year) _____. ________________________________________________________ Notary Public (Notary Seal) My commission expires on the ________day of ____________________________, (Year) ____________.

ACKNOWLEDGMENT BY PRINCIPAL IF CORPORATION STATE OF__________________ COUNTY OF ________________, To-wit: I, ____________________________________________________, a Notary Public in and for the county and state aforesaid, do hereby certify that _____________________________________________________who, as __________________________________, (Title) signed the foregoing writing for _____________________________________________, a corporation, has this day before me acknowledged the said writing to be the act and deed of said corporation. Given under my hand this ___day of ________________________, (Year)________ . (Notary Seal) _________________________________________________________ Notary Public My commission expires on the __________day of ______________________________, (Year) _______ .

ACKNOWLEDGMENT FOR SURETY STATE OF____________________ COUNTY OF __________________, To-wit: I, ___________________________________________________, a Notary Public in and for the county and state aforesaid, do hereby certify that ________________________________________________ who, as __________________________________, signed the (Name of Corporate Officer or attorney in fact) (Title /office)

the foregoing writing for __________________________________, a corporation, has this day before me acknowledged the said (Name of Surety)
writing to be the act and deed of said corporation. Given under my hand this ______day of _____________________ ,(Year) _______.

_________________________________________________ Notary Public (Notary Seal) My commission expires on the _________________day of ____________________ (Year) ____.

BOND INSTRUCTIONS IF THE PRINCIPAL IS AN INDIVIDUAL OR PARTNERSHIP: 1. 2. Complete the bond. Have a notary complete the applicable section of acknowledgment titled, ACKNOWLEDGMENT BY PRINCIPAL IF AN INDIVIDUAL OR PARTNERSHIP, on the back of the bond.

IF THE PRINCIPAL IS A CORPORATION: 1. 2. Complete the bond. Have a notary complete applicable section of acknowledgment titled, ACKNOWLEDGMENT BY PRINCIPAL IF A CORPORATION, on back of the bond. Make sure there is a raised corporate seal on the front of the bond. If the principal is a corporation and a seal has not been adopted, one may be drawn by printing the word "SEAL" and circling it.

3. 4.

SURETY: 1. 2. 3. Complete applicable part of bond. Have a notary complete applicable section of acknowledgment titled, ACKNOWLEDGMENT BY SURETY, on the back of the bond. Make sure there is a raised Surety Seal on the front of the bond and on the Power of Attorney.

GENERAL INSTRUCTIONS:
1. 2. 3. 4. 5. 6. 7.

8.

9. 10. 11.

Enter the name of the Principal, specify individual, partnership or corporation to be covered by bond. Enter the address of the principal. Enter the name of the Surety Company issuing the bond. Enter the address of the Surety Company issuing the bond. Enter the effective date of the bond. Enter the execution date of the bond. If the principal is an individual, please sign. If the principal is a corporation, the president or vice-president must sign bond and underline the appropriate title. If the bond is to be signed by someone other than the president or vice-president, attach a copy of the corporate resolutions or power of attorney showing authorization of the individual to bind the corporation. If the principal is a corporation, be sure to affix the corporate seal. If the principal has not adopted a seal, one may be drawn by printing the word "SEAL" and circling it. Enter the name of the surety. Enter signature and the title of the person having Power of Attorney to bind the surety. Affix the corporate seal of the surety.

ACKNOWLEDGMENT PREPARATION INSTRUCTIONS A. ACKNOWLEDGMENT BY PRINCIPAL IF AN INDIVIDUAL 1. 2. 3. 4. 5. 6. 7. 8. B. Enter the name of the State. Enter the name of the County. Enter the name of the Notary Public witnessing the transaction. Enter the name of the principal covered by the bond if an individual or partnership. Notary must enter the date the bond was witnessed. It must not be a date before the execution date of the bond. Affix the Notary Seal. Notary must sign his/her name. Notary enters his/her commission date.

ACKNOWLEDGMENT BY PRINCIPAL IF A CORPORATION 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Enter the name of the State. Enter the name of the County. Enter the name of the Notary Public witnessing the transaction. Enter the name of the Corporation Officer signing the bond. Enter the title of the officer signing the bond. Enter the name of the Company or Corporation. Notary must enter the date the bond was witnessed. It must not be a date before the execution date of the bond. Affix the Notary Seal. Notary must sign his/her name. Notary enters his/her commission date.

C.

ACKNOWLEDGMENT BY SURETY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Enter the name of the State. Enter the name of the County. Enter the name of the Notary Public witnessing the transaction. Enter the name of the person having the power of attorney to bind the surety company. Enter the title of the person binding the Surety Co. Enter the name of the Insurance Company (Surety). Notary must enter the date the bond was witnessed. The date must not be prior to execution date of the bond. Affix the Notary Seal. Notary must sign his/her name. Notary enters his/her commission date.

POWER OF ATTORNEY INSTRUCTIONS A Power of Attorney for the Surety must be attached. It must show that it was in full force and effect on the execution date indicated on the front page of the bond. The corporate seal must also be affixed to the Power of Attorney. a. Name of attorney in fact must be listed. b. The Power of Attorney may not exceed imposed limitations. c. The certificate date, preferably the execution date of the bond, but no earlier than the execution date, must be entered. d. The signature of the authorizing official must be affixed. The signature may be a facsimile. e. A raised seal must be affixed.