Submittal Checklist FY14 (2) - Laserfiche WebLink

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Nonprofit Grants Program Submittal Checklist for FY 2013 -14 Please go through each item on this checklist and put an "x" in the box to show what is being submitted. Fill in the other blank fields and be sure it meets the listed requirements. Include coinment(s) if you're unable to submit requested documentation or to explain special circumstances, financial cycle, etc. Sign and date the bottom and return this checklist along with your application. * Failure to include this completed and signed checklist with your application packet or to provide required supporting documents or to provide acceptable explanations of exceptions will result in the disqualification of your application. ❑ Application (Signed original and two (2) additional copies): *Only applications which utilize the official County of Hawaf i application form will be accepted. You may not alter the content or format of this application form other than to complete each section. Additional pages may, however, be attached. Comments: ❑ Proof of Authorization (Bylaws, Resolution, etc.) for binding signature. Supporting Documentation: One (1) copy of each of the following required documents: ❑ Annual Financial Statements: You are required to provide Financial Statements (Comprehensive Profit & Loss Statement or better required; Audited Statements if available) from the two most recent years. They must reflect financial operations within the past three year period (1/1/2010 — 12/31/12). (Name, title, address, and signature of preparer must appear on statement). If not prepared by a licensed CPA, Must be signed by the Executive Director or authorized member of your organization (title must be indicated, with explanation) to certify accuracy. ❑ A waiver may be granted to provide (a minimum of) one year's information if organization's date of incorporation is after January 1, 2011. Please indicate date of incorporation: Indicate below the periods reported in your Financial Statements. Explain any exceptions. 1. For Period: Comments: 2. For Period: Comments: ❑ Pages 1 & 2 of your most recent IRS Form 990. Must be for a period within the past 24 months (1 /1 /11 — 12/31/12). Period: Comments: ❑ IRS letter verifying agency's tax - exempt status (IRS 501(c)(3)). Dated: Comments: ❑ Articles of Incorporation. Signed Copy Comments: ❑ By -laws. Signed Copy Comments: ❑ Document Page(s) containing nepotism and conflict of interest clause(s): Specific reference indicating that your organization does not allow Nepotism or Conflicts of Interest must be within organizational documents (By -Laws, Official Employee handbook, employee signoff, etc.). Documents must be provided. Nepotism is defined as: appointing persons on the basis of their blood or marital relationship to the appointing authority, rather than on merit or ability. Indicate Document: Conflict of Interest is defined as: a substantial probability that action taken by an individual will result in measurable direct benefits accruing to the individual as opposed to benefits accruing in general to an industry. Indicate Document: Submitted by: Date: (Authorized Signature)