Microsoft Word - Patriot Act 2-COMPLIANCE FORM.doc



Return this checklist and all required attachments (one set per agency) listed below on or before 5:00 p.m., Thursday, February 16th, 2017 to a United Way office. Save a copy for your files.

Agency Name:

Please place all starred (*) items below in a binder clip and in order as listed.

_____*Two copies of the Volunteer Information Sheet (on Greater Ottawa County United Way website)

_____*TWO copy of a program story, which will be used publicly.

_____ *One copy of your License to Solicit (Please check the date license it is considered

EXPIRED if dated before March 31st. If license is expired, please include a copy of the application to renew).

_____ *One original copy of your signed Anti-Terrorism Compliance Measures and 501(C)3 certification. (on Greater Ottawa County United Way website)

_____ *One copy of your IRS Determination Letter.

_____*One copy of IRS Form W-9 (Request for Taxpayer Identification Number & Certification) (on Greater Ottawa County United Way website)

_____ *One copy of your most recent Form 990. Based on Form 990, what is the organization’s

overhead ratio? _____%

Formulas based on the redesigned IRS Form 990

Note: All part/line references are from the core form

Overhead Ratio calculation:

Part IX, Line 25, column C (management & gen. exp.) + Column D (fundraising exp.)

Part VIII, Line 12, column A (total revenue)

If your percentage is 35% or higher, we must have a letter signed by your organization’s Executive Director and Board President stating the reason why it is at this level and how your organization is working to bring the percentage level down.

_____ *One copy of your most recent financial audit or third party review.

Also include one copy of your agency’s management letter from your auditor during this same review period.

_____ Place an “x” on the line if you would like to apply for the 2016 SECC.

(State Employees Combined Campaign)

_____ Twelve copies of the completed program application for each program. (3-holed punched)

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2017 Program

Application Checklist

Year 2 of a 2 year process

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