2013 CFC MEMBERSHIP APPLICATION

Transcription

1 2013 CFC Membership Application, Page 1 of 9 Section One, General Introduction 2013 CFC MEMBERSHIP APPLICATION DESCRIPTION OF FORM: Thank you for your interest in the 2013 Combined Federal Campaign. The elements of the 2013 application are described below: Section One: General Introduction and Instructions Section Two: CFC Application with Certifications Section Three: AWF Affiliation Form Section Four: Attachment E Template Once you have completed the application, you must print and sign in the required space on pages 7 and 8. The signed Application Form can be submitted electronically as a PDF. Original signatures are not required but should be retained in your files for three consecutive years. WHERE TO SEND DOCUMENTS: Please submit the Application Form and all attachments in an electronic format. TO: admissions@animalwelfarefund.net FAX TO:

2 2013 CFC Membership Application, Page 2 of 9 Section One, General Introduction INSTRUCTIONS For your application to be complete, all the described schedules and attachments must be included Questions? Call us at ext CFC Application with Certifications: Paper document with signature. Failure to mark a box for each certification will result in the denial of the application. The completed application form can be ed to admissions@animalwelfarefund.net. 2. AWF Affiliation Form: Please complete, indicating you have read and understand the terms and conditions of your application. 3. Attachment A: Organizations must provide a description of the services and activities they provided in 2012, demonstrating that the organization had a substantial local presence in their geographical area. The Attachment A must include the hours and days per week of operation and the county and state where the applicant organization s office is located. Additionally organizations must show how their work supported human health and welfare. Download Detailed Attachment A Instructions. Returning members: Unless advised otherwise, we strongly recommend you update the Attachment A used in the application to the 2012 CFC. If you are unable to locate a copy of this document, please contact our office. 4. Attachment B: IRS 501(c) (3) letter. Your letter should have been issued or updated within the past 5 years (if not, request an affirmation letter by calling ). If the name of the organization differs on the IRS determination letter, the IRS Form 990, or audited financial statements, you must submit DBA or trade name documentation from the IRS or state government confirming this name change. Are you part of a group exemption? If so, you must provide a copy of the IRS letter granting the group exemption, as well as the list of subordinates that are covered by the group exemption. The EIN on the applicant s Form 990 must match the EIN on the IRS determination letter. 5. Attachment C: Organizations with revenue of $250,000 or more must include audited financial statements for a fiscal year ending on or after June 30, Attachment D: IRS Form 990 for a fiscal year ending on or after June 30, The Form 990 and audited financial statement (if applicable) must cover the same fiscal period. PLEASE NOTE: a. Your Form 990 MUST include the Signature of officer. If you are sending a PDF, make sure the 990 is signed. If it is not, you may attach the signature page in a separate file or send it as a fax. b. Applicants who filed the Form 990 electronically will need to submit a copy of an officer-signed Form EO or Form 8453-EO in lieu of an officer s signature on the Form 990. c. The Form 990 must be complete, including all supplemental statements and Schedule A (Schedule B is not required). d. Check the number of voting members listed on page 1, line 3, and the number of individuals listed in Part VII on page 7 of your Form 990. The figure on page 1 generally must match the number of individuals identified as an Individual Trustee or Director or as an Institutional Trustee in Column C of Part VII. If the figures do not match, contact us. e. If you filed a Form 990-EZ, you must provide a Pro Forma 990. Download Pro Forma Template. 7. Attachment E Template: Please use the template provided on Page 8 for the submission of your 25 word statement and taxonomy codes. REQUIRED ATTACHMENTS to be submitted with this form: 1. Attachment A Schedule of services provided in Attachment B IRS determination letter and trade name documentation if applicable 3. Attachment C Audited financial statements (if applicable) 4. Attachment D IRS Form 990

3 2013 CFC Membership Application, Page 3 of 9 APPLICATION FOR THE 2013 COMBINED FEDERAL CAMPAIGN APPLICANT CONTACT INFORMATION ORGANIZATIONAL INFORMATION: Organization Name: Primary Mailing Address: Street Address (if primary address is a P.O. Box): (We, as your federation, will use your primary mailing address. If you have provided a P.O. Box, the CFC requires that you also include a street address) Check this box if the above address is different from the address submitted with the 2012 CFC application: Public Phone: (for use in CFC printed marketing materials) Website: 5-digit CFC Code: (if unknown, leave blank) Fax: EIN: CONTACTS: Help us keep in touch with your organization by identifying which staff members should receive certain types of communication from AWF. Organization Primary Contact: The Primary Contact is the first point of contact for most communications regarding CFC applications, campaign communications and general inquiries from AWF. This person is often also authorized to certify documents with an official signature. Title: Direct telephone: Address: CFC Application Contact: (Person preparing the CFC application if different from above) Title: Direct telephone: Address: Finance Contact: Title: Direct telephone: Address: Distribution Address (if different from above):

4 2013 CFC Membership Application, Page 4 of 9 CFC CERTIFYING STATEMENTS 1) Place a check in the one appropriate box: I certify that the organization named in the application has a substantial local presence in the geographical area covered by the local campaign. Include as ATTACHMENT A supporting statements and/or documentation of substantial local presence in the geographical area covered by the local campaign and a description of the programs, services, b enefits, etc. pr ovided b y t he or ganization i n c alendar year and how t hose programs, s ervices, benefits, etc. affect human health and welfare of the target population. See Attachment A guidance Service Office Address (if different from Organization Address on previous page): Hours of Operation Per Each Day of the Week (Example: Monday-Friday, 9AM-5PM; Saturday, 10AM 3PM; Sunday, Closed): Organization s Dedicated Phone Number: County and State Where Office is Located: I certify that the applicant organization named in the application has a substantial local presence in the geographical area covered by an adjacent local campaign. Include as ATTACHMENT A supporting statements and/or documentation of substantial presence in the geographical area covered by an adjacent campaign and a description of the programs, services, benefits, etc. provided by the organization in calendar year 2012 and how those programs, services, benefits, etc. affect human health and welfare of the target population. See Attachment A guidance Service Office Address (if different from Organization Address on previous page): Hours of Operation Per Each Day of the Week (Example: Monday-Friday, 9AM-5PM; Saturday, 10AM 3PM; Sunday, Closed): Organization s Dedicated Phone Number: County and State Where Office is Located:

5 2013 CFC Membership Application, Page 5 of 9 I certify that the organization named in the application has a substantial statewide presence. (Statewide presence is defined as providing services in 30% of a state s geographic boundaries or providing services affecting 30% of a state s population). Include as ATTACHMENT A supporting s tatements and/ or doc umentation of s ubstantial statewide pr esence and a des cription of t he pr ograms, s ervices, benef its, et c. pr ovided b y t he or ganization i n calendar year 2012 and how those programs, services, benefits, etc. affect human health and welfare of the target population. 2) I certify t hat t he I nternal Revenue S ervice ( IRS) r ecognizes t he organization named i n t his a pplication as t axexempt under 26 U.S.C. 501(c)(3) and to which contributions ar e tax deductible pursuant to 26 U.S.C. 170(c)(2). Include as ATTACHMENT B a copy of the most recent IRS determination letter. See instructions for additional information. 3) Place a check in the one appropriate box: I certify that the organization named in this application is not part of a group exemption. I certify that the organization named in this application is part of a group exemption. I certify that the organization named in this application is a bona-fide chapter or affiliate that operates under a national organization s single corporation tax-exemption. 4) I certify that the organization named in this application is a human health and welfare organization providing services, benefits, or as sistance to, or c onducting ac tivities a ffecting h uman heal th a nd w elfare. T he s ervices, benefits, assistance, or program activities affecting human health and welfare provided in calendar year 2012 are reflected in ATTACHMENT A. 5) Place a check in the one appropriate box: I certify that the organization named in this application reports total revenue of $250,000 or more on its IRS Form 990 (or pro forma IRS Form 990) covering a period ending on or after June 30, 2011 and meets both of the following two conditions: accounts for its funds on the accrual basis in accordance with generally accepted accounting principles (GAAP); and, has an audit of its fiscal operations completed annually by an independent certified public accountant in accordance with generally accepted auditing standards (GAAS). (Include as ATTACHMENT C a copy of the auditor s report and the complete audited financial statements for a fiscal period ending on or after June 30, 2011.) I c ertify t hat t he or ganization nam ed in t his ap plication reports total revenue of at least $100,000 but less than $250,000 on its IRS Form 990 (or pro forma IRS Form 990) covering a period ending on or after June 30, 2011 and meets both of the following two conditions: accounts for its funds on an accrual basis in accordance with generally accepted accounting principles (GAAP); and, has an audit of its fiscal operations completed annually by an independent certified public accountant in accordance with generally accepted auditing standards (GAAS).

6 2013 CFC Membership Application, Page 6 of 9 I certify that the organization named in this application reports total revenue of less than $100,000 on its IRS Form 990 (or pro forma IRS Form 990) covering a period ending on or after June 30, 2011 and has controls in place to ensure f unds ar e pr operly accounted f or and t hat i t c an pr ovide ac curate t imely f inancial information t o i nterested parties. 6) Check the one appropriate box: I c ertify t hat t he organization n amed i n t his a pplication pr epares a nd s ubmits to t he I RS a c omplete c opy of t he organization s IRS Form 990. (Include as ATTACHMENT D a copy of the complete IRS Form 990 for a period ending on or after June 30, 2011, i ncluding s ignatures in the b ox m arked Signature of O fficer or in IRS F orms 8879-EO or 8453-EO. The preparer s signature alone is not sufficient. (IRS Forms 990EZ, 990PF, and comparable forms are not acceptable substitutes.) I certify that the organization named in this application is not required to prepare and submit an IRS Form 990 to the IRS. (Include as ATTACHMENT D a Pro Forma IRS Form 990 for a period ending on or after June 30, IRS Forms 990 EZ, 990PF, and comparable forms are not acceptable substitutes. Download Pro Forma 990 Template.) 7) I certify that the administrative and fundraising rate for the organization named in this application is %. This percentage is computed from the IRS Form 990 (or pro Forma 990) submitted with this application by adding the amount spent on "management and general" to "fundraising" and dividing the resulting total by "total revenue". Instructions for calculating overhead: Part IX Lines 25(column C) and 25(column D) located on page 10 should be added together and divided by Part VIII Line 12(column A) located on page 9. No other methods may be used to calculate this percentage. All percentages must be listed to the tenth of a percent (i.e. 10.0% or 15.5%). 8) I certify that an active and responsible governing body, whose members have no material conflict of interest and a majority of whom serves without compensation, directs the organization named in this application. 9) I certify that the organization named in this application prohibits the sale or lease of CFC contributor lists. 10) I certify that the organization nam ed in this application conducts publicity and promotional activities based upon its actual program and operations, and that these activities are truthful and non-deceptive, include all material facts, and make no exaggerated or misleading claims. 11) I c ertify t hat the or ganization nam ed i n t his application ef fectively uses t he f unds c ontributed f or its an nounced purposes. 12) I c ertify that the organization nam ed i n this a pplication i s i n c ompliance with all s tatutes, E xecutive or ders, and regulations restricting or prohibiting U.S. persons from engaging in transactions and dealings with countries, entities, or individuals subject to economic sanctions administered by the U.S. Department of the Treasury s Office of Foreign

7 2013 CFC Membership Application, Page 7 of 9 Assets Control. The organization named in this application is aware that a list of countries subject to such sanctions, a list of Specially Designated Nationals and Blocked Persons subject to such sanctions, and overviews and guidelines f or eac h s uch sanctions program c an b e f ound at Should a ny c hange in circumstances per taining t o t his c ertification oc cur a t an y t ime, t he or ganization w ill no tify O PM's O ffice of C FC Operations immediately. 13) Include as ATTACHMENT E a 25-word s tatement f or l isting in t he c ampaign c harity list. (Use the Attachment E Template provided on page 9.) CERTIFYING OFFICIAL I,, am the duly appointed representative of (Print Name) (Print Organization) authorized to certify and affirm all statements enclosed in this application. I certify that I have read all the certifications set forth in this document and affirm their accuracy. In addition, by checking the box next to the statement, I acknowledge and agree to comply with that certification. (Signature) (Typed or printed name) (Title) (Date)

8 2012 CFC Membership Application, Page 8 of 9 Section Three, AWF Affiliation Form AWF MEMBERSHIP AFFILIATION FORM Organization Name: Statement of Services The above named organization hereby seeks to affiliate with the Animal Welfare Fund (AWF) as a member for the 2013 Combined Federal Campaign. We understand that AWF will: Screen our application in accordance with the eligibility requirements of the CFC as published by the U.S. Office of Personnel Management (OPM), forwarding said application to local CFC zones which AWF enters and for which we qualify. Report to us in writing the amount of money that has been pledged to our organization in the 2013 CFC, projecting the amount we can reasonably expect to receive after local CFC administrative costs, donor non-fulfillment, and the AWF fee (see below) are taken into account; Forward to us the names and contact information of those federal donors who ask to be acknowledged by our organization; and Forward to us donated CFC funds that are received on behalf of our organization by AWF from the 2013 CFC minus any AWF fee (see below). We acknowledge that the final determination of our organization's eligibility will be made by OPM. Membership Fee Policy AWF charges a fee to those organizations it assists with CFC applications and donation management as described above. This fee is calculated based on what each organization actually receives from the CFC what we call net receipts. For the 2013 CFC, AWF will charge 5.0 percent of a member's net receipts. The fee will be capped at $1,000. Local Authorization The CFC is administered in local zones, each one of which requires a separate application. With your permission, we will submit your material to multiple zones where you may qualify. We will notify you as to where we have sent your material. Please check the box below indicating your permission: I hereby authorize AWF to submit an application on our behalf to additional local Combined Federal Campaign zones for which we may qualify. I certify by my signature below that I have read and acknowledge AWF s Affiliation Form: Certifying Signature Print or Type Name: Date: Title:

9 2013 CFC Membership Application, Page 9 of 9 Section Four, Attachment E Template AWF ATTACHMENT E Template Organization Name: Organization DBA: (Documentation must be provided in Attachment B to this application) Public Phone: Website: EIN: Administrative & Fundraising Rate: (same as Item #7 in application): TAXONOMY CODES: 1 st 2 nd 3 rd Each organization should identify three categories, in priority order, which most closely identify the type of mission, services, and activities provided. Each cell should contain only one word. The 26 categories are: A Arts, Culture, and Humanities N Recreation, Sports, Leisure, Athletics B Educational Institutions & Related Activities O Youth Development C Envir. Quality, Protection & Beautification P Human Services Multipurpose and Other D Animal Related Q International, Foreign Affairs, National Security E Health General and Rehabilitative R Civil Rights, Social Action, Advocacy F Mental Health, Crisis Intervention S Community Improvement, Capacity Building G Disease, Disorders, Medicinal Disciplines T Philanthropy, Voluntarism & Foundations H Medical Research U Science & Technology Research Institutes, I Crime, Legal Related V Social Science Research Institutes, Services J Employment, Job Related W Public, Social Benefit: Multipurpose, Other K Food, Agriculture, and Nutrition X Religion Related, Spiritual Development L Housing, Shelter Y Mutual/Membership Benefit Orgs., Other M Public Safety, Disaster Preparedness & Relief Z Other 25 WORD STATEMENT: If you are a returning 2012 AWF member, you can review your previous statement on our website Check this box if you would like to keep your 2012 statement: If you are new or revising your previous statement, please complete the field below with a statement in 25 words or less that describes the organization s program activities. The statement should not repeat the organization's name.