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.)
Benefits to Your Organization

Once your organization is approved (based on verification of your 501(c)3 or church status) anyone affiliated with your organization can access the Community Impact Center - your affiliates will just need to give the name of your organization at the counter. An email will be sent with a benefits flyer to share with your people.
IRS Letter of Determination (501c3)/LTRC4163C (for religious organizations without a 501c3 letter)

Cancelof
Board of Directors (An outline of the roles, responsibilities, and expectations of board members or other parties involved with a nonprofit organization.)

Cancelof
Signature
Date

MonthDayYear
Date
Should be Empty:

Benefits to Your Organization