Form FDACS-10114 "Solicitation of Contributions Supplemental Financial Disclosure" - Florida

What Is Form FDACS-10114?

This is a legal form that was released by the Florida Department of Agriculture and Consumer Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2014;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FDACS-10114 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-10114 "Solicitation of Contributions Supplemental Financial Disclosure" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Please return completed
SOLICITATION OF CONTRIBUTIONS
supplemental financial disclosure
SUPPLEMENTAL FINANCIAL DISCLOSURE
to:
ADAM H. PUTNAM
FDACS
Sections 496.4071, Florida Statutes
COMMISSIONER
Solicitation of Contributions
Rule 5J-7.004(4), Florida Administrative Code
2005 Apalachee Pkwy.
1-800-HELP-FLA (435-7352) • (850) 410-3800
Tallahassee, FL 32399-6500
www.FreshFromFlorida.com • 850-410-3804 Fax
A charitable organization or sponsor who had more than $1 million in total revenue and spent less than 25 percent of the
organization or sponsor’s total annual functional expenses on program service costs for the immediate preceding fiscal
year shall file the following supplemental financial information.
[s. 496.4071, F.S.]
The supplemental financial information required under s. 496.4071(1), F.S., must be filed with the department by the
charitable organization or sponsor within 30 days after receiving a request for such information from the department.
When filing the disclosure, be certain that it is completely filled out, that all questions are answered truthfully and that all
the information requested is provided. PLEASE TYPE OR PRINT. Additional pages may be attached if additional space
is needed using the same format. Please ensure that all attachments reflect the organization’s name or registration
number and the number of the corresponding question.
Name of Charitable Organization or Sponsor
CH Number
:
:
(as listed with the department)
(as isued by the department)
FINANCIAL DISCLOSURE
1.
Provide the dollar amount and the percentage of total revenue and charitable contributions allocated to
funding each of the following administrative functions:
a.
Total salaries of all persons employed by the charitable organization
or sponsor:
$
%
(of total revenue)
b.
Fundraising, including the names of any professional solicitors, amounts paid to professional solicitors, and
contributions received from professional solicitors’ campaigns:
Name of Professional Solicitor
Amount Paid
Percentage Paid
Amount Rec’d
Percentage Rec’d
(to professional solicitor)
(to professional
(from professional
(from professional
solicitor of total
solicitor)
solicitor)
revenue)
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
FDACS-10114 Rev. 11/14
Page 1 of 3
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Please return completed
SOLICITATION OF CONTRIBUTIONS
supplemental financial disclosure
SUPPLEMENTAL FINANCIAL DISCLOSURE
to:
ADAM H. PUTNAM
FDACS
Sections 496.4071, Florida Statutes
COMMISSIONER
Solicitation of Contributions
Rule 5J-7.004(4), Florida Administrative Code
2005 Apalachee Pkwy.
1-800-HELP-FLA (435-7352) • (850) 410-3800
Tallahassee, FL 32399-6500
www.FreshFromFlorida.com • 850-410-3804 Fax
A charitable organization or sponsor who had more than $1 million in total revenue and spent less than 25 percent of the
organization or sponsor’s total annual functional expenses on program service costs for the immediate preceding fiscal
year shall file the following supplemental financial information.
[s. 496.4071, F.S.]
The supplemental financial information required under s. 496.4071(1), F.S., must be filed with the department by the
charitable organization or sponsor within 30 days after receiving a request for such information from the department.
When filing the disclosure, be certain that it is completely filled out, that all questions are answered truthfully and that all
the information requested is provided. PLEASE TYPE OR PRINT. Additional pages may be attached if additional space
is needed using the same format. Please ensure that all attachments reflect the organization’s name or registration
number and the number of the corresponding question.
Name of Charitable Organization or Sponsor
CH Number
:
:
(as listed with the department)
(as isued by the department)
FINANCIAL DISCLOSURE
1.
Provide the dollar amount and the percentage of total revenue and charitable contributions allocated to
funding each of the following administrative functions:
a.
Total salaries of all persons employed by the charitable organization
or sponsor:
$
%
(of total revenue)
b.
Fundraising, including the names of any professional solicitors, amounts paid to professional solicitors, and
contributions received from professional solicitors’ campaigns:
Name of Professional Solicitor
Amount Paid
Percentage Paid
Amount Rec’d
Percentage Rec’d
(to professional solicitor)
(to professional
(from professional
(from professional
solicitor of total
solicitor)
solicitor)
revenue)
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
$
%
FDACS-10114 Rev. 11/14
Page 1 of 3
c.
Travel expenses:
$
%
d.
Overhead and other expenses related to managing and
administering the charitable organization or sponsor:
$
%
2.
Provide the names of and specific sums earned by or paid to all employees or consultants who earned or
were paid more than $100,000 during the immediately preceding fiscal year.
Name of employee or consultant:
Amount Paid:
$
$
$
3.
Provide the names of and specific sums paid to all service providers who were paid more than $100,000
during the immediately preceding fiscal year and a brief description of the services provided:
Name of service provider:
Amount Paid:
$
$
$
Description of services provided:
4.
The dollar amount and percentage of total revenue and charitable contributions allocated to programs:
Program:
Amount Paid:
Percentage:
$
%
$
%
$
%
$
%
5.
Provide the details of any economic or business transaction between the charitable organization or sponsor
and:
an officer, trustee, or director of the charitable organization or sponsor;
the immediate family of an officer, trustee, or director of the charitable organization or sponsor;
an entity controlled by an officer, trustee, or director of the charitable organization or sponsor;
an entity controlled by the immediate family of an officer, trustee, or director of the charitable organization or
sponsor;
an entity that employed or engaged for consultation an officer, trustee, or director of the charitable organization or
sponsor;
an entity that employed or engaged for consultation the immediate family of an officer, trustee, or director of the
charitable organization or sponsor.
FDACS-10114 Rev. 11/14
Page 2 of 3
NOTE: The term “immediate family” means a parent, spouse, child, sibling, grandparent, grandchild, brother-in-law,
sister-in-law, son-in-law, daughter-in-law, mother-in-law, or father-in-law.
6.
Provide additional clarifying information, if any:
CONTACT PERSON
Person responsible for completing this disclosure:
Name:
Title:
Telephone Number:
Email Address:
(
)
-
FDACS-10114 Rev. 11/14
Page 3 of 3
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