Organization Information

Instructions

Please answer the Parent Organization question with a “Yes” if you are an affiliate or subsidiary of a larger organization even if you operate under a separate tax ID #. Examples include:

Parent Organization	Subsidiary/Affiliate
School District	Individual School
Habitat for Humanity International	Local Habitat Affiliate
VFW/American Legion National	Local Post
City or County Government	Police or Fire Department

* Organization Name

* Is your org covered by an IRS group tax exemption or share a tax ID with a parent org?

* Parent Organization Name

* Parent Organization EIN Number

* Do you have a local EIN Number?

* EIN Number

* Address

Address 2

* City

* State

Country

* Zip Code

Phone

Website

* Please copy your organization's mission statement below100 words left

* Please briefly describe your organization's history, basic goals, and/or purpose200 words left

* How many Affiliates or Branches does your organization have in the US?

* Does your organization file an annual IRS Form 990?

You may be required to attach the most recent filing of this report as a part of your application; if you are not sure of your answer, please confirm with your finance department as this may impact potential funding to your organization

* What is your organization's most recently reported total annual revenue?

* What was your organization's prior year total annual revenue?

* What were your organization's most recent total annual expenses?

* What were your organization's prior year total annual expenses?

* What was your organization's most recent Net Profit/Loss?

* What is your organization's annual budget?

* What is your organization's total debt outstanding?

* Approximately how many people does your organization serve annually?

Please do not add text or symbols, only numbers (do not enter a range -- one value only please)

* Approximately how many annual volunteers does your organization have?

Contact Information

Prefix

* First Name

Middle Name

* Last Name

Suffix

* Title

* Email

* Address

Address 2

* City

* State

* Country

* Zip Code

* Phone

Phone Ext.

* Phone Type