Grantmaking Trip Sponsor Form - U.s. House Of Representatives Committee On Ethics
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1U.S. House of Representatives
Committee on Ethics
GRANTMAKING TRIP SPONSOR FORM
This form should be completed by a public charity or private foundation (both as defined under section 501(c)(3) of
the Internal Revenue Code) that provides a grant of funds to another entity to underwrite, in whole or in part, a trip
or an event, meal, or activity that will occur during a trip, or a necessary expense that will be incurred during a trip,
with express or implicit knowledge or understanding that one or more House Members or employees may
participate in or attend that trip or event, or otherwise may be beneficiaries of the gift or donation. Provide a copy
of your completed form to the primary sponsor of the trip.
NOTE: Willful or knowing misrepresentations on this form may be subject to
criminal prosecution pursuant to 18 U.S.C. § 1001. Failure to comply with the Committee’s
Travel Regulations may also lead to the denial of permission to sponsor future trips.
1. I certify that (name of your organization): ______________________________________________
has been designated a § 501(c)(3) nonprofit charitable organization by the Internal Revenue Service.
Yes
No
2. Name of Primary Trip Sponsor: ______________________________________________________
3. I certify that my organization (complete a or b):
a.
Has provided a grant, gift, or donation to the above-named Primary Trip Sponsor and conducts
an audit or review of its grant, gift, or donation to ensure that the funds are spent in accordance
with the terms of its grant, gift, or donation. or
b.
Has had a direct role in the organizing, planning, or conducting of a trip to
(destination) _____________________________ on (date) ______________________ that is
being organized or arranged by the above-named Primary Trip Sponsor.
4. Check one:
a.
My organization does not employ or retain a registered federal lobbyist or foreign agent or
b.
My organization employs a registered federal lobbyist or foreign agent, but their involvement
in planning, organizing, or arranging the trip was de minimis under the travel regulations.
5. I certify that I am not a registered federal lobbyist or foreign agent for any sponsor of this trip.
6. I certify by my signature that the information contained in this form is true, complete, and correct to
the best of my knowledge.
Signature: _______________________________________________________________________
Name: _____________________________________ Title: ______________________________
Organization: ____________________________________________________________________
Address: ________________________________________________________________________
Telephone number: ______________________ Email: __________________________________
If there are any questions regarding this form please contact the Committee at the following address:
Committee on Ethics
U.S. House of Representatives
1015 Longworth House Office Building
Washington, DC 20515
(202) 225-7103 (phone)
(202) 225-7392 (general fax)
Version date 4/2013 by Committee on Ethics
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