Application Form For Payroll Deduction - Office Of The Secretary Of State - State Of South Carolina
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STATE OF SOUTH CAROLINA
OFFICE OF THE SECRETARY OF STATE
APPLICATION FOR PAYROLL DEDUCTION
All fundraising agencies should return this form and all attachments to: South Carolina Secretary of State
Attn: Payroll Deductions
Post Office Box 11350
Columbia, South Carolina 29211
**If you are a member organization of a fundraising agency, please forward your information to the
fundraising agency rather than sending it directly to the Secretary of State’s Office.
: ___________________________________________________________________
Name of Charitable Organization
: _________________________________________________________
Charitable Organization’s Registration Number
________________________________________________________________________________
Contact Person:
: _____________________________________________________________________________________
Address
: ____________________________________
: __________________________________________
Telephone
Fax
: ________________________________________________________________________________
E-mail Address
I hereby certify that the above is a nonprofit, eleemosynary corporation, association or organization and is organized and
operated exclusively for charitable, health or welfare services to the public and meets all of the following qualifications:
1. Is and continues to be organized and qualified to solicit and operate under the laws of this state, pursuant to Chapter 56 of
Title 33 (“South Carolina Solicitation of Charitable Funds Act”);
2. Provides direct and continuing services to or on behalf of the citizens of South Carolina. For purposes of this section,
“direct and continuing services” means: (a) services other than legal advocacy services which are provided directly to and
specifically for one individual or one family; or, (b) services which are in the nature of medical research; or, (c) services which
involve the collection and administration of funds by umbrella organizations for other organizations, all of which qualify under
the Act;
3. Is recognized as tax exempt under Section 501(c)(3) of Title 26, United States Code (the Internal Revenue Code of 1954, as
amended);
4. Is not an organization contemplated by Section 501(c)(4), 501(c)(5), or 501(c)(6) of Title 26, United States Code (the
Internal Revenue Code of 1954, as amended) and is not an organization primarily engaged in the propagation of a religious
faith or belief; this prohibition shall include, but not be limited to, organizations primarily engaged in lobbying or political
activity;
5. Is operated without discrimination in regard to all persons served, and complies with all requirements of law, including
administrative regulations, respecting non-discrimination and equal opportunity regarding its officers, staff, employees and
volunteers;
6. Has neither a parent organization nor a subsidiary organization which fails to meet qualifications herein contained in items 1
through 5.
Sworn to and Subscribed before me:
__________________________________________________
Signature of Chief Executive Officer
this ________ day of ___________, 20____
__________________________________________________
___________________________________
Chief Executive Officer (Print Name)
Notary Public of South Carolina
My Commission Expires:
__________________________________________________
Date
Payroll Deduction Application
Form Revised by South Carolina
Secretary of State, April 2008
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