Potential Partner Intake Form - Imagine with a Mission

Community Partner - General Information

Legal Business Name

Legal Entity Type

Other

State of Incorporation

If not incorporated, input N/A

Business Address

Street Address

Street Address Line 2

CityState

Zip Code

Business Email Address

example@example.com

Business Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Federal ID/EIN #

State Tax ID (if applicable)

Community Partner - Main Point of Contact

Full Name

First NameLast Name

Title

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Personal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

List all owners - please note that a resume/curriculum vitae (CV) must also be attached for each owner.

Owner 1 Full Name

First NameLast Name

Owner 2 Full Name

First NameLast Name

Owner 3 Full Name

First NameLast Name

Owner 4 Full Name

First NameLast Name

What method do you use to pay yourself and other owners?

Business Financial Overview

What is your current business annual revenue?

Do you regularly work with an accountant or professional bookkeeper for your business finances?

If you currently have a dedicated business bank account, what is the name of your bank?

Are your business and personal funds and transactions completely separate?

If you know your business credit score, please provide

Do you have outstanding business loans (or personal loans used for business purposes); if so, are you current on your payments?

Did you file taxes for your business last year

Human Resources Overview

List all key employees and provide a brief job description of each

Employee 1 - Full Name

First NameLast Name

Employee 1 - Job Description

Employee 2 - Full Name

First NameLast Name

Employee 2 - Job Description

Employee 3 - Full Name

First NameLast Name

Employee 3 - Job Description

Employee 4 - Full Name

First NameLast Name

Employee 4 - Job Description

If you pay employees, are you current on your payroll taxes?

If you utilize volunteers, what is the approximate number of volunteers for this year?

Do you feel that you have sufficient staff/volunteer support to carry out your mission?

Do you employ/work with Independent Contractors (non-W2 staff) this calendar year?

If so, do you have current W9 forms on file for each?

If you do had contractors last year, did you file your 1099 with the IRS and provide a copy to each contractor?

How do you pay our employees and contractors?

Business Planning and Operational Overview

Do you have a current and/or updated written business plan?

Do you have an active Sales Plan and/or Fundraising Strategy?

Do you have systems and automations in place to sustain the operations of. your business?

What are your primary business goals for the next 12 months?

What are your primary business long-term goals (3-10 years)?

What is your biggest need at this time?

What is your biggest barrier to growth?

What is hindering you?

How do you integrate your faith in your business?

How do you measure success in your business?

Community Partner And/or Owner Current or Pending Litigation

Does the Community Partner have any current or pending litigation?

If yes, please provide a description of the current of pending litigation:

Do any Community Partner other owners have any current or pending litigation?

If yes, please provide a description of the current of pending litigation:

Community Partner - Insurance

List the name of the insurance agency that the requesting entity is insured with - please note that an insurance declarations page showing all types and amounts of insurance coverage must be submitted.

Name of Insurance Agency

Community Partner - a Potential Partnership with Imagine with a Mission

Identify the IWAM project for which the Community Partner seeks funding:

Identify the duration of the project:

Name the skills and expertise (e.g. construction, counseling, tutoring) of the Community Partner:

Provide information of any relevant experience with similar projects:

Provide three relevant references for projects completed by the Community Partner:

Reference 1 - Full Name

First NameLast Name

Reference 1 - Organization/Business and Title

Reference 1 - Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reference 1 - Email

example@example.com

Reference 2 - Full Name

First NameLast Name

Reference 2 - Organization/Business and Title

Reference 2 - Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reference 2 - Email

example@example.com

Reference 3 – Full Name

First NameLast Name

Reference 3 - Organization/Business and Title

Reference 3 - Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reference 3 - Email

example@example.com

COMMUNITY PARTNER – BUDGET REQUESTED

Identify the total amount of requested funding:

Identify the total amount of funding needed in the first 90 days of the project:

Provide a budget breakdown – specify how the requested funding will be used:

Provide estimated timelines for any project milestones:

Community Partner – Justification

With wich IWAM pillar does your business most closely align?

Describe why the Community Partner’s mission aligns with the goal of the IWAM project:

Please describe if your business primarily serves to STABILIZE those in crisis, EQUIP and help plan for growth, foster others to THRIVE, or a combination of the three.

Community Partner - Checklist of Documents Needed for Submission

Please submit only PDFs

Creation document (Articles of Incorporation or Articles of Organization)

If a nonprofit, copy of your By Laws

If a nonprofit, copy of current annual registration with the Secretary of State

If a nonprofit, copy of most recent 990 tax retrn filed with the IRS

If tax exempt under 501(c)3-6, include IRS determination letter

Copy of active Business License, if applicable

Resume/CV of Owner 1

Resumer/CV of Owner 2

Financial Statement for Most Recent Fiscal Year

Insurance declarations page showing all types and amounts of insurance coverage

Organizational projected budget, including detailed project/program budget. Include all sources of revenue

Any other supporting documentation regarding budget, timeline or partner mission alignment with IWAM

Please confirm all documents are uploaded.

Signature