North Carolina



NC State Surplus Property

Non-Profit - Tax-Exempt Organization Qualification Request

Name of Organization: _____________________________________________Date: ________________

Address of Organization: ________________________________________________________________

____________________________________________________________________________________

City State Zip Code

Employer Identification Number: ____________________________________________________

Contact person: _______________________________ Telephone: ______________________________

E-mail: ______________________________________ Fax: ____________________________________

NC State Surplus Property is authorized to enter into negotiated sales of surplus property to Non-Profit, Tax-Exempt organizations within the state per North Carolina General Statute 143-64.03(b). Non-Profit Tax-Exempt organization is defined by the following:

NC General Statute 143-64.02(2)

“Nonprofit tax exempt organizations" means the following entities certified by the Internal Revenue Service as tax-exempt nonprofit organizations under section 501(c)(3) of the United States Internal Revenue Code of 1954: medical institutions, hospitals, clinics, health centers, school systems, schools, colleges, universities, schools for the mentally retarded, schools for the physically handicapped, radio and television stations licensed by the Federal Communications Commission as educational radio or educational television stations, public libraries, civil defense organizations, and nonprofit entities that are qualified under rules adopted by the State Surplus Property Agency of the Department of Administration to refurbish computers and donate them to low-income students or households throughout the State.

Attach the following documentation:

• Letter from the IRS recognizing your organization as Non-Profit and Tax-Exempt;

• Copy of license issued by the NC Agency that regulates your organization;

• Letter on organization letterhead with details of the purpose and function of your organization;

• List of Officers of the organization, position and their contact information (including address);

• Name of one person authorized to purchase property on the organization’s behalf.

Please check the category(s) of your organization below:

Only these types of organizations are eligible

[ ] Medical Institution [ ] Hospital [ ] Clinic [ ] Health Center [ ] School System

[ ] School [ ] College [ ] University [ ] School for the Mentally Retarded

[ ] School for the Physically Handicapped [ ] Public Library [ ] Civil Defense

[ ] Radio or Television Station Licensed by the FCC as Educational Radio or Television

[ ] Computer Refurbishers who donate to low-income students or households

I certify that the information presented is accurate, current and complete. I understand that all property purchased shall remain in use and is subject verification by the State Surplus Property Agency for twelve months from date of purchase.

Date: ________________ Name of Authorized Officer: ______________________________

Signature: _____________________________________________

Title: _________________________________________________

SEAL State of North Carolina_____________, County of ________

Subscribed and sworn to before me this day of

Notary Public: _________________________________________

My commission expires: _________________________________

Non-Profit Tax Exempt Organization Qualification Regarding Refurbished Computers for Donation to Low-Income Students or Households

To be eligible to purchase surplus computers pursuant to NCGS 143-64.03, the following requirements must be met. Please provide the information requested along with the notarized qualification request form. Additional quarterly reporting is required to remain eligible.

Requirements:

1. Your non-profit must serve a recognized Federal or State “low income” population.

2. Each state-owned computer acquired by your non-profit must be donated.

3. Quarterly report in Microsoft Excel or Word detailing the quantity of computers purchased, the number of computers donated, and the number of students or households in each county served. Reports are due no later than the tenth day of each quarter end (January, April, July and October)

4. All other reporting as requested by the State of North Carolina.

On a Separate Document:

1. List the Federal or State program whose definition of “low-income” is followed by your program. Give the definition and a web link to the federal or state program it mirrors.

2. Per the definition, describe how the population your program serves and your distribution process. Tell how students or households are identified to receive donations.

3. Describe how you your non-profit furthers the statutory requirement to donate refurbished computers throughout the state. Identify, by county, where computers are donated and the plans to reach students or households who may not currently receive your service.

Mail Package to: NC State Surplus Property

6501 Chapel Hill Road

1310 MSC

Raleigh, NC 27699-1310

Definitions

State Surplus defines the organizations above as follows:

1. Medical institutions, hospitals, clinics, health centers.

A facility staffed by a minimum of one licensed physician. The facility must be licensed by the North Carolina Department of Health and Human Services. The organization must provide health care to citizens of the state of North Carolina.

2. School systems, schools, colleges, universities, schools for the mentally retarded, schools for the physically handicapped.

An institution providing education. The school must provide a minimum of 2 years of successive learning to students of the State of North Carolina. The school must be licensed by the Department of Public Instruction or the Department of Administration. The school must have an open admissions program.

3. Radio and television stations licensed by the Federal Communications Commission as educational radio or educational television stations,

Must be based in North Carolina.

4. Public libraries

Must be based in North Carolina.

5. Civil defense

Includes organizations such as Fire Departments and Rescue squads. Must be based in North Carolina.

6. Computer Refurbishers

Must be based in North Carolina. Must complete additional documentation required by the State Surplus Property Office.

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