PARTNER AGENCY APPLICATION. Our Mission: No One Goes Hungry in Central & Eastern North Carolina

Transcription

1 PARTNER AGENCY APPLICATION Our Mission: One Goes Hungry in Central & Eastern rth Carolina

2 Our Service Area & Branches Durham Branch 2700 Angier Avenue, Suite A Durham, rth Carolina Serving Chatham, Durham, Granville, Orange, Person and Vance counties Greenville Branch 1712 Union Street Greenville, rth Carolina Serving Carteret, Craven, Edgecombe, Jones, Lenoir, Onslow, Pamlico, Pitt, and Wilson counties New Bern Branch 205 South Glenburnie Road New Bern, rth Carolina Serving Carteret, Craven, Jones, Onslow, and Pamlico counties Raleigh Branch (Main Office) 1924 Capital Boulevard Raleigh, rth Carolina Serving Duplin, Edgecombe, Franklin, Nash, Lee, Wilson Halifax, Harnett, Johnston, Sampson, Wake, Warren, and Wayne counties Sandhills Branch 195 Sandy Avenue Southern Pines, rth Carolina Serving Lee, Moore, Richmond, and Scotland counties Wilmington Branch 1314 Marstellar Street Wilmington, rth Carolina Serving Brunswick, Columbus, New Hanover, and Pender counties

3 Dear Friend, Thank you for your interest in the Food Bank of Central & Eastern rth Carolina. Enclosed is an application for partner agency membership, which must be completed, signed and returned to the Food Bank. In addition to this form, documentation of your organization s nonprofit, tax-exempt status is required. Your application will not be considered without proof of one of the following: (1) Federal tax-exempt status as a 501(c)(3) organization. A copy of the determination letter from the Internal Revenue Service is required. (2) A copy of a current letter, written on letterhead stationery, from the governing church body (i.e., Baptist State Convention or Seventh Day Adventist) documenting its exempt status and the church s membership in that organization. (3) Completion of the enclosed form titled Documentation List for Independent Churches and other religious organizations. Any program charging a fee for services also must show that at least 50% of the clients are eligible according to federal poverty guidelines. You will be contacted by a Food Bank agency services and programs representative when the completed application form and proof of your organization s non-profit, tax-exempt status has been received. At that time, an appointment will be set to meet with you at your organization to discuss your program in greater detail if it appears to qualify for partnership with the Food Bank. If you have any questions, call the branch that services your county. Sincerely, The Food Bank of Central & Eastern rth Carolina Who we are and what we do: Food Bank CENC is a non profit organization that serves 34 counties in central & eastern rth Carolina. In fiscal year 16/17, the Food Bank distributed nearly 67 million pounds of food through a network of partner agencies. The Food Bank has warehouses in Durham, Greenville, New Bern, Raleigh, Sandhills (Southern Pines), and Wilmington. The Need In the 34 counties served by the Food Bank, more than 600,000 people are at risk of hunger. Over 200,000 of them are children. Over 46,000 are seniors living at or below the poverty line. The Choices 77% of the people at risk of hunger have had to choose between food & paying utilities. 62% of people at risk of hunger have had to choose between food and paying rent/mortgage. 77% of people at risk of hunger have had to choose between food & getting medicine or medical care.

4 Section 1: General Information To be filled out by all applicants. Date Name of Organization Physical Address City State Zip County Mailing Address (if different) City State Zip Billing Address (if different) City State Zip Name of Director or Contact Person Phone Number Alt. Phone Number Fax Address Website Alternate Address Does your organization have a tax exempt status under section 501(c)(3) from the Internal Revenue Service? If yes, please submit a copy of your determination letter from the IRS. If no, please continue with Section 2. Section 2: Documentation of n-profit and Tax-Exempt Status Is your organization part of a larger parent organization? (i.e. church that is part of a larger church body such as the United Holy Church of America, Inc. or agency that operates under the umbrella of a nonprofit 501(c)(3) charity). If it is, will your parent organization be legally responsible for the operation and liabilities of your program? Does your parent organization have tax exempt status under section 501(c)(3) from the Internal Revenue Service? If yes, please submit a copy of their determination letter from the IRS. Parent Organization and sponsored agency must complete the 501 (c)(3) Sponsor Agreement and submit it with the application. Name of Organization Physical Address City State Zip County Name of Director or Contact Person Phone Number

5 Section 3: Feeding Programs Emergency Food Pantry Providing groceries to those in need of supplemental or short-term food assistance. Soup Kitchen Cooking and serving meals to walk-in guests on a regular or occasional basis. Children s Program Providing meals or snacks to children through after school programs, back pack programs, etc. Emergency Shelter An agency providing on-site meals in addition to providing housing and other services, i.e.; homeless and domestic violence shelters. Day Program Eats on-site but lives off-site, i.e.; Senior Nutrition Programs, Seasonal Programs, etc. Emergency Assistance Health related problems/crisis intervention. Other School pantries, etc. Please select the categories that accurately describes your program. Section 4: Program Information Please describe your program s pantry space. Include size and type of shelving. Attach photos of your food storage space, including refrigerators and freezers. How many refrigerators do you use for your program? How many freezers do you use for your program? Please describe the basic purpose of your program and the overall services. Attach copies of brochures or printed documentation on your food program s service plan. List all sources of funding for your program. Please attach your food program budget to the application. Why does your agency wish to partner with the Food Bank?

6 Section 4: Program Information What primary population does your program serve? How long has your program been in existence? How many people are on your staff? Does your program take referrals? If yes, from which social service organizations does your program take referrals? Please describe your program s screening process. Attach any copies of forms the program uses for screening applicants, brochures or printed documentation on your food program. What is your mission statement? What days/hours are you open to assist clients? Days Hours Days Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday Does your program keep records of food distribution or meals served? If yes, what is the average number of households served each month? If yes, what is the average number of meals served each month? What are your program s current food sources? Check all that apply. Purchase Food Community Food Donations Grocery Store Food Donations Government Commodities Are clients charged a fee for services? If yes, are scholarships available, sliding scale, etc.?

7 With respect to product received from the Food Bank of Central & Eastern rth Carolina, the undersigned agency agrees that in distributing that product to its clients: Agencies must strictly adhere to eligibility criteria for distribution of food that is part of state and/or federal programs. Products must be distributed without adding to, reducing or otherwise modifying the eligibility criteria. All other Food Bank of Central & Eastern NC product will be distributed to all persons who qualify for agency assistance, and the agency will not discriminate against any person based on one s race, creed, national origin, religious affiliation or lack thereof, sex or sexual orientation. This Agreement is of indefinite duration, and it may be terminated by either part at any time. To the best of my knowledge the above information is correct. Signature

8 Section 5: Liability Release Agency Name, (hereinafter referred to as Agency ) located at, hereby affirms that the original donor, the Food Bank of Central & Eastern rth Carolina, and Feeding America: 1. Are released by the Agency from any liabilities resulting from the donated Product. 2. Are held harmless from any claims or obligations in regard to the Agency or the donated Product. 3. Offer no express warranties in relation to the Product. Agency Representative Signature Printed Name of Agency Representative and Title Date

9 Section 6: Counter-terrorism Compliance In compliance with the spirit and intent of the USA PATRIOT Act and other counter-terrorism laws, the Food Bank of Central & Eastern rth Carolina (FBCENC) requests that each partner agency ( Organization ) certify that it is in compliance with FBCENC s compliance program. Organization Name Check the appropriate box to indicate your compliance with each of the following: This Organization is not on any federal terrorism watch lists, including the list in Executive Order 13224, the master list of specially designated nationals and blocked persons maintained by the Treasury Department, and the list of Foreign Terrorist Organizations maintained by the State Department. This Organization does not, will not and has not knowingly provided financial, technical, in-kind or other material support or resources* to any individual or entity that is a terrorist or terrorist organization, or that supports or funds terrorism. This Organization does not, will not and has not knowingly provided or collected funds or provided material support or resources with the intention that such funds or material support or resources be used to carry out acts of terrorism. This Organization does not, will not and has not knowingly provided financial or material support or resources to any entity that has knowingly concealed the source of funds used to carry out terrorism or to support Foreign Terrorist Organizations. This Organization does not regrant to organizations, individuals, programs and/ or projects outside of the United States of America without compliance with IRS guidelines. This Organization takes reasonable, affirmative steps to ensure that any funds or resources distributed or processed do not fund terrorism or terrorist organizations. This Organization takes reasonable steps to certify against fraud with respect to the provision of financial, technical, in-kind or other material support or resources to terrorists and terrorist organizations. * Comply means that your organization does not support terrorist groups or activities. Comply* Do t Comply In this form, material support and resources means currency or monetary instruments or financial securities, financial services, lodging, training, expert advice or assistance, safehouses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine or religious materials. I certify on behalf of the Organization listed above that the foregoing is true. Signature of Legally Authorized Title of Legally Authorized Name of Donee Organization Date

10 Section 7: Agency Development and Capacity Building Review Does your agency have an active board of directors? How often do they meet? Does your organization rely solely on donations to operate? Does your organization have a succession plan to continue hunger outreach in the event of your absence? Do you have a volunteer recruitment and retention plan? Have you collaborated with other agencies in the community? Does your agency currently use Social Media as a way of raising hunger awareness? Are you comfortable speaking to groups about your partnership with us and the impact its making in the community? Are you considering expanding your food program? If yes, what resources are needed to increase distribution and successfully expand the capacity of your food program? Please check all that apply. Refrigerator Freezer Funding Volunteers Facility Vehicles What is the operating budget for your food program (please attach copy)? Are you or any staff members Food Safety certified? Does your organization currently provide Food and Nutrition Services (i.e. Food Stamp) outreach? If not, is your agency willing to provide Food and Nutrition Services outreach to its clients?

11 Section 8: Agency Agreement This document is an agreement ( Agreement ) made between the Food Bank of Central & Eastern rth Carolina ( FBCENC ) located at 1924 Capital Blvd., Raleigh, NC and ( Agency ) located at (Agency Address) In this Agreement the Agency makes representations and warranties to FBCENC and agrees with FBCENC to all of the following terms and conditions. If there is any inaccuracy in any representation made by the Agency, any breach of any warranty made by the Agency, or any breach by the Agency of any term or condition or failure of the Agency to perform its obligations according to the terms or conditions, then FBCENC has the right, without further investigation, to stop distributing product to the Agency and/or follow processes outlined in the FBCENC s Probation, Suspension, Termination, and Grievance Policy (found in FBCENC s Agency Policy Manual) concerning further distribution of product to the Agency. 1. Requirements: The Agency agrees to abide by the policies, procedures, and record keeping requirements of the FBCENC. 2. IRS Eligibility Requirements: The Agency represents and warrants that it meets the IRS eligibility requirements for the receipt, transfer, and use of donated products (food and non-food) under section 170(e)(3) of the Internal Revenue Code ( Code ), as stated below: A. 501(c)(3) or Church/Religious Organization: The Agency represents and warrants that it is (or is sponsored by) (i) a corporation which is an organization described in section 501(c)(3) of the Code which is exempt under section 501(a) of the Code and which is not a private foundation as defined in section 509(a) of the Code or (ii) a church or religious organization as defined by the Internal Revenue Service and, in either case, that the Agency (or its sponsor) satisfies all of the criteria below for the applicable type of eligible organization. Check the type of organization that the Agency (or its sponsor) will qualify as: Corporation described in section 501(c)(3) of the Code other than a private foundation - If this box is selected, the Agency is required to submit, prior to Agency approval: A currently valid determination letter from the Internal Revenue Service verifying its status as an organization described in section 501(c)(3) of the Code which is exempt under section 501(a) of the Code and which is not a private foundation as defined in section 509(a) of the Code. The name of the corporation in the determination letter must match the name that the Agency is known by in the community. If the Agency s name does not match the name of the corporation in the determination letter, the Agency is required to submit current (less than one year old) official and verifiable documentation indicating that the Agency is the corporation named in the determination letter. If the Agency does not have its own determination letter (and is not covered by a group ruling or determination letter from the Internal Revenue Service) but is sponsored by a church, religious organization or corporation, which is an organization described in section 501(c)(3) of the Code other than a private foundation as defined in section 509(a) of the Code, then the Agency and its sponsor must complete and sign FBCENC s Agency Sponsorship Agreement every two years, and the sponsor must provide a copy of its determination letter verifying the sponsor s status as an organization described in section 501(c)(3) of the Code which is exempt under section 501(a) of the Code and which is not a private foundation as defined in section 509(a) of the Code.

12 Section 8: Agency Agreement Church or Religious Organization (as defined by the Internal Revenue Service) If this box is selected, the Agency is required to provide one of the following forms of documentation before Agency approval or anytime thereafter upon FBCENC s request: Churches or religious organizations that are part of a larger body a copy of a current letter written on organizational letterhead stationary, from the governing body of the church or religious organization documenting the church s or religious organization s membership in the larger body. The governing body of the church or religious organization must also provide a copy of the group exemption letter from the Internal Revenue Service verifying that the larger body of which the church or religious organization is a part is a church or religious organization described in section 501(c)(3) of the Code. Churches that are not part of a larger church body a completed copy of the FBCENC s Documentation List for Independent Churches & Other Religious Organizations along with the supporting documents required by such form. B. Purpose of Incorporation and Service: The Agency represents and warrants that it is organized to serve the ill, needy, or infants (minor children 0-18 years old) as defined in the Treasury Regulations corresponding to section 170(e)(3) of the Code. The Agency also represents and warrants that that it is not organized for a purpose unrelated to serving the ill, needy, or infants (such as publication of a non-profit periodical providing information to members). C. Distribution without Charge: The Agency agrees that it will distribute the donated products (food and nonfood items) obtained from FBCENC free of charge (not in exchange for money, volunteer hours, services or other consideration). D. Recipients of Distributed Products: The Agency agrees that it will only distribute donated products to persons who qualify as ill, needy, or infants (minor children 0-18 years old) as defined in section 170(e)(3) of the Code. The Agency also agrees that it will not distribute donated products to persons who do not qualify as ill, needy, or infants as defined in section 170(e)(3) of the Code. E. Use of Donated Products: The Agency agrees that it will not sell or use donated products in exchange for money, other property or services, including using donated products for the purpose of fundraising programs and events. The Agency also agrees that it will comply with the restrictions on the use and transfer of donated property, as described in section 170(e)(3) of the Code and the corresponding Treasury Regulations, including section 1.170A-4A(b)(2) and (3). F. Bartering, Selling and Fundraising Use Prohibited: The Agency agrees that it will not barter, sell or use any donated products obtained from FBCENC for fundraising purposes. 3. Area of Distribution: The Agency agrees that it will only distribute products received from FBCENC in FBCENC s 34-county service territory (any exceptions to this must be cleared with FBCENC). The Agency also agrees that it will not distribute any products outside of the United States and Puerto Rico. 4. Record Keeping: The Agency agrees that it will maintain adequate books and records that accurately reflect the total amount of product received and distributed (or used), a description of the products and the date of its receipt. The Agency also agrees to outline its procedure for determining that the final recipient of the product is ill, needy or an infant (a minor child 0-18 years old). 5. Availability of Records: The Agency agrees to make its books and records, including but not limited to those which track the receipt and distribution of products obtained from FBCENC and financial record keeping books available upon request to the Internal Revenue Service, the rth Carolina Department of Agriculture and FBCENC, with or without notice. 6. Local, State and Federal Regulations: The Agency agrees that it will ensure the donated product conforms to any applicable provisions of the Federal Food Drug and Cosmetic Act (as amended), and any applicable regulations. The Agency also agrees that it will handle products in conformity with all local, state and Federal regulations, and will maintain current licenses as required by local, state and Federal regulations.

13 Section 8: Agency Agreement 7. Storage and Handling of Products: The Agency agrees that it will store, handle and distribute products consistent with the Federal Food, Drug and Cosmetic Act and any applicable regulations. 8. Food Safety: The Agency agrees that at least one staff person of the Agency will be trained in food safety from a food safety training course approved by FBCENC. Approved trainings are FBCENC Food Safety Training Workshops, ServSafe Certification, National Restaurant Association Certification, and Food Handlers Card, or other approved safety training curriculum. The Agency also agrees that if it utilizes food provided by FBCENC to make meals, the Agency s key food service program staff will receive ANSI certified manager-level food safety certification. 9. Donor Stipulations: The Agency agrees that it will adhere to any donor stipulations placed on donated products. 10. As Is Condition: The Agency agrees that it will accept all products received from FBCENC in as is condition. 11. Shared Maintenance, Transportation and Value Added Processing Fees: The Agency agrees to pay any applicable Shared Maintenance and/or handling fees (Value Added Processing, Delivery Charges, Transportation fees) charged by FBCENC for the products received from FBCENC. 12. Purchased Product: The Agency agrees that if it should choose to purchase non-donated product from FBCENC, then it may pay FBCENC any extra charges and costs associated with that product. 13. Local Donations from Feeding America National Donors: If the Agency receives donations directly from a nationally affiliated Feeding America donor, such as Walmart, Food Lion, Sam s Club, etc. through the FBCENC Retail Donation Program, the Agency agrees to abide by the specific procedures and record keeping requirements related to these donations. 14. Discrimination: The Agency agrees that it will not engage in discrimination, in the provision of service, against any person because of race, color, citizenship, religion, sex, national origin, ancestry, age, marital status, disability, sexual orientation including gender identity, unfavorable discharge from the military or status as a protected veteran. 15. On-Site Inspections: The Agency agrees to allow representatives of FBCENC, donors and government agencies to inspect and audit all facilities and vehicles where products received from FBCENC are received, stored and distributed, with or without notice. 16. Authorized Agent: The Agency agrees to have only an authorized agent(s) (i.e. shoppers) pick-up or receive products from FBCENC. The Agency also agrees to make known to FBCENC a list of authorized agents and contact FBCENC when a change is made to that list. All new shoppers must attend a Food Bank new shoppers orientation session. Shoppers for new agencies must attend a new agency orientation session prior to agency status being granted. 17. Access to One Feeding America Member Food Bank: The Agency agrees that it will only receive food from FBCENC and no other Feeding America Member Food Bank. 18. Liability Release Form: The Agency agrees to execute and submit to FBCENC the FBCENC s Liability Release for Donated Food Bank Product form, and any other liability release forms that FBCENC may require at any time. 19. Active/Inactive Agency Designation: The Agency agrees that it will obtain products from FBCENC at least every three months to be deemed an active Agency. If the Agency becomes inactive, then the Agency will not be allowed to obtain products from FBCENC. If the Agency becomes inactive, the Agency agrees that it will complete the agency application process again, prior to being reinstated as an active Agency allowed to obtain products from FBCENC. 20. Termination of Agency Agreement: The Agency or FBCENC can terminate this agreement, with or without cause, at any time. 21. Multiple Locations and Sub-distribution: The Agency agrees that it will only receive and store product from FBCENC at multiple locations if such locations (i) individually meet the requirements of this Agreement, (ii) have been inspected by FBCENC, and (iii) are approved by FBCENC prior to receiving and distributing food. The Agency is not allowed to sub-distribute donated

14 Section 8: Agency Agreement product to any organization, agency, partner, or entity other than a qualifying client or approved FBCENC Partner Agency (and then only if the donated product is in excess of what the Agency can distribute through its normal channels). 22. FBCENC Agency Policy Manual: The Agency agrees that it has received and will abide by the rules, regulations and guidelines at all times set forth by the FBCENC Agency Policy Manual. The Agency s authorized representative s signature below confirms that the Agency is accepting and agrees to abide by all terms of this agreement. Agency Signatures: Name of Agency Title Print Name of representative who signed this agreement Authorized Agency Signature (must be signed on behalf of the Agency by the highest authority in the organization who is responsible for any and all actions of the organization) Date