NAME OF APPLICANT AGENCY: Organization Information 1. Nature of Business Organization type: For-profit Non-profit Not-for-profit IRS tax-exempt status: Non-exempt Exempt IRS Code Section: – 2. Corporation Data: Are the following documents up to date? Document Description Item YES NO Corporate Documentation (i.e., Certificate(s) of Incorporation; By-laws; Policy & a. Procedures as requested herein) Fidelity Bond b. Insurance Policies for property: c. Liability Vehicle Malpractice/Liability insurance to protect agency/staff against lawsuits brought by d. recipients of services IRS Form 501C Tax Exempt Status e. – IRS Form 4029 Application for Exemption form Social Security and Medicare Taxes – f. and Waiver of Benefits IRS Form 990 Return of Organization Exempt from Income Tax g. – IRS Form 941 Employer’s Quarterly Federal Tax Return h. – Delaware Annual Franchise Tax Report i. Delaware Forms (VCE - UC8A) W1-W3 Report of State Withholding j. Contracts for Purchased Services (i.e., Rent, etc.) k. Delaware Business License l.. Finance, Accounting, and Internal Controls 3. Basis of accounting system: Cash Accrual 4. Does the firm engage an independent auditor to conduct an annual audit of financial statements? Yes No
NAME OF APPLICANT AGENCY: Organization Information 1. Nature of Business Organization type: For-profit Non-profit Not-for-profit IRS tax-exempt status: Non-exempt Exempt – IRS Code Section: 2. Corporation Data: Are the following documents up to date? Item Document Description YES NO a. Corporate Documentation (i.e., Certificate(s) of Incorporation; By-laws; Policy & Procedures as requested herein) b. Fidelity Bond c. Insurance Policies for property: Liability Vehicle d. Malpractice/Liability insurance to protect agency/staff against lawsuits brought by recipients of services e. IRS Form 501C – Tax Exempt Status f. IRS Form 4029 – Application for Exemption form Social Security and Medicare Taxes and Waiver of Benefits g. IRS Form 990 – Return of Organization Exempt from Income Tax h. IRS Form 941 – Employer’s Quarterly Federal Tax Return i. Delaware Annual Franchise Tax Report j. Delaware Forms (VCE - UC8A) W1-W3 Report of State Withholding k. Contracts for Purchased Services (i.e., Rent, etc.) l.. Delaware Business License Finance, Accounting, and Internal Controls 3. Basis of accounting system: Cash Accrual 4. Does the firm engage an independent auditor to conduct an annual audit of financial statements? Yes No
HSS_18002A_OudCoe_appC3.docx