Partners in Education Tax Credit Program Scholarship Granting Organization Initial Application This application provides notification to the South Dakota Division that the petitioning Scholarship Granting Organization (SGO) of Insurance (“Division”) will participate in the Partners in Education Tax Credit Program The SGO is required to provide annual notification to the Division of its (“Program”). intent to participate in the Program. Section I: Scholarship Granting Organization Information: (Use tab key, arrow keys, or mouse click to navigate form fields.) The South Dakota Division of Insurance will publish the scholarship granting and business contact organization’s name information on the website while the organization is participating in the Partners in Education Tax Credit Program. Division’s Part A: SGO Basic Information Scholarship Granting Organization Name Federal Employer Identification Number Business Street Address City State ZIP SD Mailing Address: (check if mailing address is same as principal address) State City ZIP SD Primary Contact Position/Title Primary Contact Email Phone Fax Organization Website Organization Public Email (if different from email provided for primary contact) Part B: Additional Scholarship Granting Organization Management, Officers and Employees Information (proof of background checks for each must be attached) Name: Name: Name: Position/Title: Position/Title: Position/Title: Name: Name: Name: Position/Title: Position/Title: Position/Title: Part C: Scholarship Granting Organization Board Member Information: (proof of background checks for each must be attached) Name: Name: Name: Address: Address: Address: City/State/ZIP City/State/ZIP City/State/ZIP SD SD SD Telephone: Telephone: Telephone: Date of Appointment Term of Service Date of Appointment Term of Service Date of Appointment Term of Service Name: Name: Name: Address: Address: Address: City/State/ZIP City/State/ZIP City/State/ZIP SD SD SD Telephone: Telephone: Telephone: Date of Appointment Term of Service Date of Appointment Term of Service Date of Appointment Term of Service Part D: Other Date 501(c)(3) status was awarded by United States Internal Revenue Service (IRS): This SGO operates on financial (fiscal) year that runs from to to This SGO will first provide Program educational scholarships in the school year running from
Partners in Education Tax Credit Program Scholarship Granting Organization Initial Application This application provides notification to the South Dakota Division of Insurance (“Division”) that the petitioning Scholarship Granting Organization (SGO) will participate in the Partners in Education Tax Credit Program (“Program”). The SGO is required to provide annual notification to the Division of its intent to participate in the Program. Section I: Scholarship Granting Organization Information: (Use tab key, arrow keys, or mouse click to navigate form fields.) The South Dakota Division of Insurance will publish the scholarship granting organization’s name and business contact information on the Division’s website while the organization is participating in the Partners in Education Tax Credit Program. Part A: SGO Basic Information Scholarship Granting Organization Name Federal Employer Identification Number Business Street Address City State SD ZIP Mailing Address: (check if mailing address is same as principal address) City State SD ZIP Primary Contact Position/Title Primary Contact Email Phone Fax Organization Website Organization Public Email (if different from email provided for primary contact) Part B: Additional Scholarship Granting Organization Management, Officers and Employees Information (proof of background checks for each must be attached) Name: Name: Name: Position/Title: Position/Title: Position/Title: Name: Name: Name: Position/Title: Position/Title: Position/Title: Part C: Scholarship Granting Organization Board Member Information: (proof of background checks for each must be attached) Name: Name: Name: Address: Address: Address: City/State/ZIP SD City/State/ZIP SD City/State/ZIP SD Telephone: Telephone: Telephone: Date of Appointment Term of Service Date of Appointment Term of Service Date of Appointment Term of Service Name: Name: Name: Address: Address: Address: City/State/ZIP SD City/State/ZIP SD City/State/ZIP SD Telephone: Telephone: Telephone: Date of Appointment Term of Service Date of Appointment Term of Service Date of Appointment Term of Service Part D: Other Date 501(c)(3) status was awarded by United States Internal Revenue Service (IRS): This SGO operates on financial (fiscal) year that runs from to This SGO will first provide Program educational scholarships in the school year running from to
pietcp_sgo_initial_application_packet.docx