Charitable Organizations Application Form (Page 4 of 4) in pdf

Charitable Organizations Application Form Page 4

year which was spent for fund raising and administration is unavailable due to

accounting preparation, please provide an estimated percentage:______________

19.

Name of and amount of compensation paid to the five (5) individuals whose

annual compensation exceeds the reporting requirements on IRS Form 990:

__________________________________________________________________

20.

Has any director, officer, member, trustee, partner, senior level executive or

employee of the charitable organization been convicted of a felony, pled nolo

contendere to a felony charge, or been held liable in a civil action involving fraud,

embezzlement, fraudulent conversion or misappropriation of property? Yes___

No ___ If yes, please provide details:

________________________________________________________________________

The application must be signed by two authorized officials of the organization one of

whom is a director or trustee.

I CERTIFY UNDER PENALTY OF PERJURY THAT I HAVE READ THIS

APPLICATION AND KNOW THAT ALL STATEMENTS THEREIN ARE TRUE.

DATE: _____________

_________________________________________

(Print applicant’s name)

_________________________________________

(Print name of director or trustee)

_________________________________________

(Authorized signature of director or trustee)

_________________________________________

(Print name of second director or trustee)

_________________________________________

(Authorized signature of second director or trustee)

DB-Charities Form

Revised 5/04

Charitable Organizations Application Form Page 4