Agency Name:_______________________________________ 

Location:___________________________________________

Please circle yes or no to each statement

1.     I certify that the Internal Revenue Service recognizes the organization named above as tax-exempt under 26 U.S.C. 501(c) (3) and to which contributions are tax deductible.  (Attach a copy of your IRS notification of 501 (c) (3) status. If applicable, include a copy of the “Doing Business As” (D.B.A.) letter for any name change).

Yes                        No

2.     I certify that the organization named above is registered as a non-profit corporation.  (First-time applicants should enclose a copy of their official non-profit approval).

Yes                        No

3.     I certify that the organization named above uses standards of accounting and a financial system based on generally accepted accounting principles (GAAP).

Yes                        No

4.     Please answer only one of the following questions:

I certify that the organization named above was audited in accordance with generally accepted auditing standards (GAAS) by an independent certified public accountant.

Yes                        No

-OR-

I certify that the organization named above has annual revenues less than $100,000 and therefore is exempt from submitting an audit by an independent certified public accountant.  (Annual revenue is determined by Line 12 of the IRS Form 990).

Yes                        No

5.     Please include your EIN number  _____________________ . 

6.     The following is the non-discrimination policy requirement for certification; you must check ‘yes’ to qualify:

“I certify that the organization named above has a policy and procedure of non-discrimination with regard to race, color, religion, national origin, disability, age, gender or sexual orientation applicable to the charitable organization’s paid and volunteer staff; applicable to membership on the charitable organization’s governing board; and applicable to persons served by the charitable organization.”

Yes                        No

7.     I certify that the organization named above conducts publicity and promotional activities based upon its actual programs and operations and that these activities are truthful and non-deceptive, include all material facts, and make no exaggerated or misleading claims.

Yes                        No

8.     I certify that the organization named above uses contributed funds for its announced purposes and that the organization’s activities are consistent with its stated goals and objectives.

Yes                        No

9.     I certify that the organization named above conducts its fiscal operations in accordance with a detailed annual budget that is prepared and approved at the beginning of each fiscal year by the Board of Directors.  Prior authorization by the Board of Directors shall be required for any significant variation from the approved budget. 

Yes                        No

10. I certify that the organization named above maintains a “substantial local presence,” i.e., staffed facility, office or portion of a residence and a phone line dedicated exclusively to this organization, available to its clientele or members of the public seeking this agency’s services or the benefits it provides, and which is open at least 15 hours per week.

 Yes                        No 

11. I certify that the organization named above is a human health and welfare organization that provides services to or conducts activities affecting human health and welfare.

Yes                        No

12. I certify that the organization named above has been in business for at least 12 months prior to submitting this application.

Yes                        No

We certify that we have read all the certifications set forth in this document and that our signatures below signify that we acknowledge and agree with such certifications: