Contact InformationOrganization's Full Legal Name* Brand Names, Trade Names, and/or Acronyms Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Physical Address Same as Mailing* Yes No Physical Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Website Organization's President/Executive Director* First Last Title* Phone*Fax PhoneEmail Address* Contact Person (if different) First Last Title PhoneFax NumberEmail Address Organizational InformationIs the Organization a 501(c)(3)?* Yes No Year Established* Federal Tax ID Total Organization Budget* Total Number of Board Members* Total Number of Staff* Total Number of Volunteers* Mission Statement*Brief Description of Organization*What is the faith background of the Organization?*Is the Organization associated with a local church?* Yes No Which one and how long?*Does the church recommend and/or support the Organization?*Population and Geographic Areas Served*Describe model of care used for clients the Organization serves:*What is your staff training program?*Has the Organization worked with a non-profit before?*(Provide details on that relationship and experience.)Is the Organization currently able to cover its regular monthly expenses?* Yes No How is the Organization currently funded?* Does the Organization receive any government funding?* Yes No Please describe:*Provide at least two references that have a history of working with the Organization:*Organizational Information ExhibitsExhibit A: A Brief History of the Organization Drop files here or Select files Max. file size: 1,000 MB. Exhibit B: List of Board of Directors and Officers Drop files here or Select files Max. file size: 1,000 MB. Exhibit C: IRS Determination Letter/501(c)(3) Letter Drop files here or Select files Max. file size: 1,000 MB. Exhibit D: Most Recent IRS Form 990 or 990 EZ Drop files here or Select files Max. file size: 1,000 MB. Exhibit E: Articles of Incorporation Drop files here or Select files Max. file size: 1,000 MB. Exhibit F: Audited Financial Statement if available Drop files here or Select files Max. file size: 1,000 MB. SignatureMinistry Representative's Name* First Last Consent* By typing my name above I am recognizing it as an electronic signature.
