Nonprofit/Church application

Community Non-Profit/Church Application

Thank you so much for your interest in partnering with the CIC — we’re excited about the opportunity to work together! You might be wondering why this form is required in order to receive donated goods. Completing it helps us ensure that we stay in compliance with IRS guidelines (including your IRS determination letter and board responsibilities) for distributing donated items. It also allows us to confirm who is authorized to pick up items on behalf of your organization. We truly appreciate your cooperation and look forward to serving our community together!

Agency/Church Name*

Parent Organization (If you are part of a larger organization that oversees other separate local chapters or organizations)

Address*

City*

State*

Postal Code*

Authorizing Officer*

First NameLast Name

Authorizing Officer Title*

Email*

example@example.com

Tax Exempt Number (EIN number)

Group Number (You may not have this number. The IRS only gives a group number to show that a local nonprofit is part of a larger parent organization’s tax-exempt status.)

All members of my organization can access the CICLimited members can access the CIC (see the list below or attached file)

Attach a list of approved shoppers here if you have more than 6, but still would like to limit who can access the CIC.

1

2

3

4

5

6

IRS Letter of Determination (501c3)/LTRC4163C (for religious organizations without a 501c3 letter)*

Signed Non-Profit Agreement (A signed nonprofit agreement is a formal document that outlines the roles, responsibilities, and expectations of board members or other parties involved with a nonprofit organization.)*

Signature*

Date*

Date