Place a check by each box to indicate that you have provided all necessary application materials. Any application submitted without the following materials cannot be processed. Your agency’s annual financial statement for your most recent fiscal year. Agencies whose annual budget is less than $50,000 may submit form 990 from the Internal Revenue Service (IRS) in lieu of an audit report. A copy of the IRS 501(c)3 letter establishing your agency’s tax-exempt status. A list of your agency’s current of Directors, their addresses, and a meeting schedule for the most recent year. A copy of the most recent annual report detailing your agency’s local activities. (An agency brochure may be submitted if an annual report is not published.) A copy of your agency’s annual budget, detailing that your administrative (management and general) and fundraising expenses do not exceed twenty-five percent of your total expenses. Please see sample, "Statement of Financial Expenses." (Attachment 1) Signed W-9 form. (Attachment 2) Signature I certify that the agency described herein is eligible to receive contributions which may be deducted on the contributor’s Iowa individual tax return in accordance with Internal Revenue Code sections 501(a) and 501(c)3, and which otherwise meets the criteria provided for in the Iowa Department of Administrative Services Rules Chapter 11—71(8A). (Please see page 4.) I also certify that this agency operates without discrimination in employment in accordance with Iowa Code Chapter 216. (Please see link on page 4.) Agency Representative Signature Date Print or Type Agency Representative Name Please return completed application to: Iowa Department of Administrative Services One Gift Program Hoover Building, Level A 1305 East Walnut Street Des Moines, IA 50319 If you have questions, you may contact the One Gift Coordinator, Marsha Webb, by email at or by phone at 515-281-8989. You may also visit the One Gift website at .
Place a check by each box to indicate that you have provided all necessary application materials. Any application submitted without the following materials cannot be processed. Your agency’s annual financial statement for your most recent fiscal year. Agencies whose annual budget is less than $50,000 may submit form 990 from the Internal Revenue Service (IRS) in lieu of an audit report. A copy of the IRS 501(c)3 letter establishing your agency’s tax-exempt status. A list of your agency’s current of Directors, their addresses, and a meeting schedule for the most recent year. A copy of the most recent annual report detailing your agency’s local activities. (An agency brochure may be submitted if an annual report is not published.) A copy of your agency’s annual budget, detailing that your administrative (management and general) and fundraising expenses do not exceed twenty-five percent of your total expenses. Please see sample, "Statement of Financial Expenses." (Attachment 1) Signed W-9 form. (Attachment 2) Signature I certify that the agency described herein is eligible to receive contributions which may be deducted on the contributor’s Iowa individual tax return in accordance with Internal Revenue Code sections 501(a) and 501(c)3, and which otherwise meets the criteria provided for in the Iowa Department of Administrative Services Rules Chapter 11—71(8A). (Please see page 4.) I also certify that this agency operates without discrimination in employment in accordance with Iowa Code Chapter 216. (Please see link on page 4.) Agency Representative Signature Date Print or Type Agency Representative Name Please return completed application to: Iowa Department of Administrative Services One Gift Program Hoover Building, Level A 1305 East Walnut Street Des Moines, IA 50319 If you have questions, you may contact the One Gift Coordinator, Marsha Webb, by email at or by phone at 515-281-8989. You may also visit the One Gift website at .
agency_application.docx