HomeMy WebLinkAboutSubmittal Checklist FY2021-22
Nonprofit Grants Program Submittal Checklist for FY 2021-22
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 comment(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 (one original, no additional copies) with your applicationpacket or to provide required supporting documents (one set per packet) or to provide acceptable explanations of
exceptions will result in the disqualification of your application.
Application (Signed original and three (3) additional SINGLE SIDED copies): *Only applications which utilize the current
official County of Hawai`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:
Supporting Documentation: One (1) copy of each of the following required documents per packet:
Proof of Authorization (Bylaws, Resolution, etc.) for binding signature. Must be authorized by Board to sign contracts.
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 (1/1/2018 – 12/31/20). (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, 2019. 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. If you filed electronic (e-Postcard) version (990N) provide receipt of filing. Must be for a period within the past 24 months (1/1/19 – 12/31/20). 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 (as defined below) must be within organizational
documents (By-Laws, Official Employee handbook, employee signoff, etc.). Documents must be provided with applicable clause(s) highlighted. If your documents do not contain this specific language with an indication that it applies to all members of the organization (not just officers, etc.), it is your responsibility to ensure that the verbiage fully encompasses the
intent of the provided definitions. It is recommended that you incorporate this specific language prior to the submission of your grant application.
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)
*** If grant awarded, Grantee will be required to provide a Certificate of Liability Insurance ($1,000,000 general liability, $50,000 eachoccurrence), specifically and explicitly stating the County of Hawai‘i is an additional insured.