1.) Filing receipt from Charities Registration Bureau OR 2.) Letter on agency letterhead stating agency is exempt as a religious organization 3.) Charities Registration Number: to find agencies registration number SECTION F of Directors (Please provide the following in a narrative or with an attachment). – Item Program County RHY Regional Office Coordinator 1.) List of the Board of Directors 2.) of Directors Qualifications: experience and/or training in the legal, fiscal and service aspects of youth programs. Can be demonstrated through: Resume ● Degrees ● Affiliations ● 3.) Notarized statement, signed by the chief executive officer of a municipality or president of the Board of Directors stating: "to the best of my knowledge, no member of the Board or its advisory bodies is directly or indirectly engaged in any business which conflicts with the discharge of his/her duties as a member of the Board." SECTION G County Approval (Please provide the following with an attachment). – Item Program County RHY Regional Office Coordinator 1.) Program is part of the County Child and Family Service Plan OR Addendum SECTION H Articles of Incorporation (Please provide the following information with an attachment). – Item Program County RHY Regional Office Coordinator Copy of articles of incorporation and all amendments For residential programs, articles containing a corporate purpose clause empowering the agency "To care for destitute, delinquent, abandoned, abused, neglected or dependent children.” 3.) that corporate papers have been filed with the Department of State OCFS-4836 (01/2016) SECTION I Signatures – SIGNATURE: Date: Submitted by Program Director SIGNATURE: Date: Reviewed and submitted By County RHY Coordinator
1.) Filing receipt from Charities Registration Bureau OR 2.) Letter on agency letterhead stating agency is exempt as a religious organization 3.) Charities Registration Number: to find agencies registration number SECTION F – of Directors (Please provide the following in a narrative or with an attachment). Item Program County RHY Coordinator Regional Office 1.) List of the Board of Directors 2.) of Directors Qualifications: experience and/or training in the legal, fiscal and service aspects of youth programs. Can be demonstrated through: ● Resume ● Degrees ● Affiliations 3.) Notarized statement, signed by the chief executive officer of a municipality or president of the Board of Directors stating: "to the best of my knowledge, no member of the Board or its advisory bodies is directly or indirectly engaged in any business which conflicts with the discharge of his/her duties as a member of the Board." SECTION G – County Approval (Please provide the following with an attachment). Item Program County RHY Coordinator Regional Office 1.) Program is part of the County Child and Family Service Plan OR Addendum SECTION H – Articles of Incorporation (Please provide the following information with an attachment). Item Program County RHY Coordinator Regional Office Copy of articles of incorporation and all amendments For residential programs, articles containing a corporate purpose clause empowering the agency "To care for destitute, delinquent, abandoned, abused, neglected or dependent children.” 3.) that corporate papers have been filed with the Department of State OCFS-4836 (01/2016) SECTION I – Signatures Submitted by Program Director SIGNATURE: Date: Reviewed and submitted By County RHY Coordinator SIGNATURE: Date:
OCFS-4836-revised%20form-Request-for-RHY-or-TIL-Program.docx