2026 General Campaign Donor Choice Agency Certification

United Way of Buffalo & Erie County Impact Areas are Healthy Community, Youth Opportunity, Financial Security, and Community Resiliency. Unrestricted donations to our United Way help us continue to fund these focus areas. The Donor Choice Program (DCP) is a courtesy where we offer our donors the (other) option to designate to another Health and Human Service not-for-profit, that is currently eligible to receive tax-deductible charitable contributions under section 501(c)(3) of the Internal Revenue Code. Agencies shall complete this form to be considered for prospective contributions through our GENERAL PUBLIC SUPPORT CAMPAIGN.

This form pertains to United Way of Buffalo & Erie County ONLY and is NOT related to other campaigns or appeals, such as the NYS SEFA, which is a separate process.

PLEASE READ CAREFULLY. This will require about 10-15 minutes of your time (to start, you will need the agency's EIN and contact info). Helpful hints are provided. A confirmation will immediately be sent to the respondent's email address upon successfully submitting it. Have questions? Visit https://uwbec.org/contact

Complete this form for your specific branch or chapter location for the noted year.
Use mixed case or proper letter format (avoid using all CAPS or lower-case letters).
Most fields are required and marked with a red asterisk; otherwise, leave blank.
Avoid coping and pasting page contents onto this form. Hidden html elements, links, and tags may produce errors.
Please double check correctness and for errors before submitting this document.
The Signatory Name at the bottom will be the person to certify on behalf of this agency.
Be sure to "white-list" our United Way to help ensure important communication with your agency.

Respondent's Email Address

A confirmation will be sent to this email upon successful completion (email will be from noreply@jotformsign.com)

Vendor #

This agency's Vendor ID can be found at the top of your check stub (directly under "Payee"). LEAVE BLANK if unknown.

Organization EIN (Employer Identification Number)

9-digit EIN used for 501(c)(3) bearer in IRS records

Nonprofit Name (Legal Name)

Primary name by which this organization is listed in IRS records

Also Known As (AKA) Name

Abbreviation, acronym, AKA, dba, or, if you are NOT the actual EIN holder. Leave blank if N/A.

Has your agency's Street or Mailing address recently changed?

Main Address

Street Address

CityState (abbreviation)Zip Code (5-digit)Country

Do you have a separate Mailing Address, such as a PO Box?

Mailing Address [if different from street or main address]

Mailing Address

CityState (abbreviation)Zip Code (5-digit)Country

Does this agency provide a direct Health or Human Service (HHS) as a main part of their Mission?

Mission Statement

Main purpose of this charity's existence [275-character max].0/275

Organization Website

Alternate Organization Website

Use this field if you want to add a second website, Facebook page, etc. LEAVE BLANK IF N/A.

Business Phone

Main business number w/ area codeFormat: (000) 000-0000.

General Email Address

A "general" email address that is regularly monitored, and will not change due to employee turnover, etc. If you do not have a generic email, please enter your preferred contact email for this agency

Primary Contact's Full Name

Person responsible for donations and correspondence

Primary Contact's Work Title

Primary Contact's Email

Important business emails may be sent to this email

Chief Executive Officer's Full Name

Lead person in charge of this local organization

Chief Executive Officer's Work Title

Chief Executive Officer's Email

Board Leadership Full Name

Unpaid lead board member's name

Board Leadership Title

Lead board member's title within THIS charity organization (Board Chair, Treasurer, etc.)

Board Leadership Contact Email

For the event we need to send an email to this contact (LEAVE BLANK if none)

Board Leadership Employer

CVO employer, if applicable (LEAVE BLANK if none)

Charitable Status & Anti-terrorism Conditions (please read carefully)

Funds received through United Way of Buffalo & Erie County and/or their donors are used for charitable purposes only.
We are currently eligible to receive tax-deductible contributions under section 501(c)(3) of the Internal Revenue Code (IRC) and continue to maintain a good standing with the IRS and State Charities Bureau or regulators. Our 990 or 990-N is current, if required to file, and our charitable status is currently valid.
In compliance with U.S. counterterrorism and economic sanctions laws, our organization affirms that it does not and will not knowingly provide financial or material support to any individual or entity involved in terrorism or subject to applicable sanctions, and that all funds received from United Way and their donors will be used in accordance with these laws, statutes, and executive orders.

CHARITABLE STATUS & ANTI-TERRORISM COMPLIANCE

Signatory Full Name

Individual who is certifying on behalf of this agency

Date Signed

Optional

Important info directly pertaining to this agency, if any. 0/250

PLEASE REVIEW ALL DETAILS BEFORE SUBMITTING THIS FORM.

Please ensure you entered a complete Main and/or Mailing Address. After submitted, you will promptly receive a confirmation and an email (from noreply@jotformsign.com). We appreciate your time and consideration in helping us keep this process streamlined - THANK YOU!