2021 LA SCCC - Charity Application

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Definition of Eligibility:

Health and human service non-profit organizations registered through the Louisiana Secretary of State, meeting all requirements set forth in LA R.S. 42:456(A)(3) and the Louisiana Administrative Code, Title IV, Part III, Chapter 11 (herein referred to as the Rule) are eligible to apply to be part of the Louisiana State Combined Charitable Campaign (LA SCCC).

Submission Instructions:

Each organization seeking inclusion in the 2021 LA SCCC must complete an application and provide all requested documentation. If any information is omitted, the application will be considered incomplete and declined for inclusion in the 2021 campaign.

Charitable organizations that did not apply or did not qualify in 2020, are required to submit a completed application with ALL attachments requested in this application.

Charitable organizations that were approved in 2020, are only required to submit a completed application with Attachments A, B, C, F, G and H.

Attachment files MUST not include any spaces within file names. (This will cause issues with viewing files.)

Do not use Internet Explorer within this application process. Please consider using Chrome or Firefox when completing this online form.

Documentation and all contents must correspond to the applicant’s legal name and Federal Tax Identification Number (EIN). Organizations applying under a trade name must provide certification issued by the Louisiana Secretary of State. Tax documentation must be in compliance with IRS deadlines. Audit, financial compilations or other financial documentation must meet the requirements of the Louisiana Legislative Auditor.

As part of the review process, information may be requested to certify eligibility. Failure to furnish information within 10 days of request constitutes grounds for the denial of eligibility. The burden of demonstrating eligibility shall rest with the applicant.

Application Fee:

There is a non-refundable $250 application fee. Credit card payment is required within this online application process. If you wish to pay via check or money order, please submit your application using the printed application found online at www.lasccc.org/application.

Deadline Instructions:

The deadline for submitting an application is Monday, March 1, 2021.

How to Save your Application:

Simply select the SAVE option at the bottom of the screen and get a Shareable Link or create a JotForm account.

Save your Shareable Link - this is key because this link directs you to your saved application and all future changes made.

E-mail each contact the Shareable Link and ask them to review and approve the application as needed. Once their review and actions are complete they also must SAVE their changes.

Notification of Outcome of Application Review:

Letters will be mailed by the Louisiana Division of Administration no later than June 30, 2021, to the Chief Executive Officer (CEO), using the CEO mailing address provided within this application.

______________________________________________________________________

If you have any questions, please feel free to call 225-218-2613 or e-mail sccc@launitedway.org.
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Legal name:* This field is required.Charitable Organization's Legal Name (as currently registered with the Louisiana Secretary of State)
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Trade NameIf your organization wishes to be listed in the 2021 LA SCCC Charity List using a trade name, please provide the trade name below:
(You are required to provide proof of trade name registration with the LA Secretary of State Office)
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Trade Name RegistrationIf your organization would like to be listed in the LA SCCC Charity List using a trade name, please attach your trade name registration provided by the Louisiana Secretary of State. NOTE - Please ensure file names of attachment files have no spacing. (This ensures you are able to review as needed.)
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Max. file size: 10.6MB
Trade Name Registration as provided by the Louisiana Secretary of State.
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Organizational Information:* This field is required.(Quarterly disbursements will be mailed to the address provided below. The website and telephone number provided below will be used in the 2021 LA SCCC Charity List.)
Organizational Mailing Address (Street, City, State, Zip)
Organizational Website
Organizational Telephone Number
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Primary Staff Contact:* This field is required. (LA SCCC correspondence about activities, trainings, deadlines and donor contact lists will be sent to this staff contact.)
Full Name
Telephone Number
E-mail Address
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Application Staff Contact:* This field is required.(Please indicate the authorized staff contact who is able to receive questions/requests related to this application submittal. This contact along with the CEO/Executive Director will receive a confirmation e-mail once the application is finalized and submitted.)
Full Name
Telephone Number
E-mail Address
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Description of Services:* This field is required.(Provide an organizational description to be used in the 2021 campaign materials. This description cannot exceed 25 words. When published in the LA SCCC Charity List, your organization’s name, website address, organizational phone number and regions served will be added to your description. If exceeding 25 words, discretionary edits will be made to reduce wording.) Please do not write in first person and use complete sentences. EXAMPLE: Offers free health and human services to those in need throughout the capital region.
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Please list the health and human services your charity provides within the state of Louisiana:* This field is required.
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What was the estimated dollar value of services provided to the citizens of Louisiana by your organization between January 1, 2020 and December 31, 2020?* This field is required.
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Please identify regions served by your charity:Review the map below and on the next page identify which regions are served by your charitable organization.
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Please indicate which Region or Regions is served by your charitable organization:* This field is required.(See previous page for map of regions)
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ALL REGIONS
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Attachment A
Current IRS Form 990 filed with the IRS (signed by an authorized officer)

A 990 EZ cannot be used.

If your charity has filed an extension to file your most recent 990, please submit documentation of this request and its approval.

If you are a charity applying under your national or parent organization’s name and using its EIN, please submit the national 990 filed. State Pro Formas, not filed with the IRS, will not be accepted.

A CPA or accountant signature is not acceptable and will not fulfill this requirement.

If your organization is not required by the IRS to submit a Form 990, complete pages 1, 2, 9, and 10 in order to fulfill this requirement. You may write at the top of the first page of Form 990 “For LA SCCC Purposes Only”.
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What is the last day of your annual fiscal year?* This field is required.(Your attached 990 must correspond with IRS deadline and the closure of your fiscal year.)
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Federal Tax Identification Number (EIN) for this application:* This field is required.- Your 990’s organizational EIN must correspond with the number provided below. - If your charity is a subordinate organization covered in a group extension, please list the EIN # for both your subordinate organization and central organization.
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Provide the name and title of officer providing signature of approval on the submitted 990* This field is required.(must match the signature and date of filing found on the filed 990):
Name
Title
Date when your charity filed this attached 990 (actual date filed)
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Attachment A* This field is required.- Current IRS Form 990 filed with the IRS (signed by an authorized officer). - If your charity has filed an extension to file your most recent 990, please submit documentation of this request and its approval. - If you are a charity applying under your national or parent organization’s name and using its EIN, please submit the national 990 filed. State Pro Formas, not filed with the IRS, will not be accepted. - A CPA or accountant signature is not acceptable and will not fulfill this requirement. - If your organization is not required by the IRS to submit a Form 990, complete pages 1, 2, 9, and 10 in order to fulfill this requirement. You may write at the top of the first page of Form 990 “For LA SCCC Purposes Only”. NOTE - Please ensure file names of attachment files have no spacing. (This ensures you are able to review as needed.)
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Max. file size: 29.3MB
Must include signature of authorized officer.
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The FRA is the total support and revenue (restricted and unrestricted) that an organization allocates to fundraising and administrative expenses. To be eligible to participate in the LA SCCC, your FRA must not exceed 25%.

Complete the calculation using your attached 990 (corresponding with the legal name and EIN provided within application).
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FRA Calculation Data:* This field is required.
Mgmt. & Gen. + Fundraising Expenses = “Functional Expenses” on Page 10 of Form 990 (Line 25, Columns C + D)
Total Revenue = “Total Revenue” on Page 9 of Form 990 (Line 12, Column A)
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FRA Calculation:* This field is required.Mgmt. & Gen. + Fundraising Expenses / Total Revenue (Must not exceed 25%)
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Charitable organizations that were approved in 2020, are only required to submit Attachments A (found in Part B), B, C, F, G, and H. (To determine if your charity was an approved 2020 LA SCCC Charity, please access the 2020 Charity List by clicking here.)

To determine eligibility in accordance with the Rule, the following information must be submitted and correspond with the applicant’s legal name and EIN provided.

NOTE - Please ensure file names of attachment files have no spacing. (This ensures you are able to review as needed.)
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Was your charity an APPROVED 2020 LA SCCC Charity?* This field is required.
YESNO
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Attachment B
Most recent CPA Audit, Compilation or Sworn Financial Statement (board approved).

Please provide your most recent, board approved audited financial statement conducted by a CPA.

This statement must be completed by the deadline required by the Louisiana Legislative Auditor, corresponding with the closure of your annual fiscal year. (Report must be completed within a year of this application.)

Financial statements that are outdated or delinquent will not be accepted.

Your organization may submit a compilation or sworn financial statement if within Louisiana Audit Guidelines (these guidelines consider the size of your operational budget).
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Attachment B* This field is required.Most recent CPA Audit, Compilation or Sworn Financial Statement (board approved).
Report is for fiscal year ending:
Date of Report:
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Attachment B* This field is required.Most recent CPA Audit, Compilation or Sworn Financial Statement (board approved). NOTE - Please ensure file names of attachment files have no spacing. (This ensures you are able to review as needed.)
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Max. file size: 13.0MB
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Attachment C* This field is required.Board Approved Annual Budget for the Current Fiscal Year (12 month period) NOTE - Please ensure file names of attachment files have no spacing. (This ensures you are able to review as needed.)
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Max. file size: 3.0MB
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Attachment D
Registration with the LA Secretary of State or proof of Congressional Charter

Provide a copy of your original certificate issued by the LA Secretary of State and ensure this certificate corresponds with the Name provided in Part A.

If you do not have an original certificate issued by the LA Secretary of State, provide a copy of the page displaying your organization’s name as listed in the database on the LA Secretary of State’s website: https://coraweb.sos.la.gov/CommercialSearch/CommercialSearch.aspx.

If you possess a congressional charter, provide documentation of this charter.
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Attachment D* This field is required.Registration with the LA Secretary of State or proof of Congressional Charter Please provide a copy of your original certificate issued by the LA Secretary of State and ensure this certificate corresponds with the Name provided in Part A. If you do not have an original certificate issued by the LA Secretary of State, provide a copy of the page displaying your organization’s name as listed in the database on the LA Secretary of State’s website: https://coraweb.sos.la.gov/CommercialSearch/CommercialSearch.aspx. If you possess a congressional charter, provide documentation of this charter. NOTE - Please ensure file names of attachment files have no spacing. (This ensures you are able to review as needed.)
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Max. file size: 3.0MB
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Attachment E* This field is required.Proof of IRS 501(c)(3) Status (corresponding to the Name and EIN provided in application). If your charity is a subordinate organization covered in a group extension, please provide documentation for both your subordinate organization and central organization. NOTE - Please ensure file names of attachment files have no spacing. (This ensures you are able to review as needed.)
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Max. file size: 3.0MB
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Attachment F* This field is required.List of Current and Immediate-Past Term Board Members and Board Officers. NOTE - Please ensure file names of attachment files have no spacing. (This ensures you are able to review as needed.)
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Max. file size: 3.0MB
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Attachment G* This field is required.A digital copy of your organizational logo (JPG or PNG file). NOTE - Please ensure file names of attachment files have no spacing. (This ensures you are able to review as needed.)
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Max. file size: 1.0MB
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Attachment H
$250 Application Fee. All fees are non-refundable.

At the end of the application process once CEO and Board Officer approval has been granted, please take this final step and submit payment.
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Certification & Approval by Authorized Agents:

For this section, please ask your Charity's CEO/ExecutiveDirector and Volunteer Board Officer to review the entire application and its content/attachments and complete Part E in full.

Simply select the SAVE option at the bottom of the screen and get a Shareable Link or create a JotForm account.

Save your Shareable Link - this is key because this link directs you to your saved application and all future changes made.

E-mail each contact the Shareable Link and ask them to review and approve the application. Once their review and actions are complete they also must SAVE their changes.

Once all approvals are received, please COMPLETE your application by paying the Application Fee and review/submit.
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Certifications by Authorized Agents* This field is required.The Louisiana State Combined Charitable Campaign requires that all organizations applying for admission certify compliance with the requirements as outlined in this Campaign Application, as well as, LA R.S. 42:456(A)(3) and the Louisiana Administrative Code Title 4, Part III, Chapter 11. As authorized agents, we certify that:
all of the organizational information provided in Part A is accurate and may be used within LA SCCC materials and marketing efforts as needed.
this organization is a health and human services charity and is not organized for cultural, educational, religious or political purposes as defined in §1109 of the Rule.
an equivalent amount collected as contributions through the LA SCCC will be spent to provide services and benefits primarily to the citizens of Louisiana unless there is an exception granted under the requirements of the Rule.
funds received by the LASCCC will not be used for fundraising and administrative costs.
this organization is in compliance with the USA Patriot Act of 2001.
this organization has no outstanding debt owed to a state agency.
this organization currently is not under investigation for any reason.
this organization is governed by a board of directors which meets regularly and whose members serve without compensation.
this organization is an active, non-profit in good standing with the LA Secretary of State Office.
this organization has substantial local presence within the state of Louisiana.
this organization is in compliance with and is not included on the Louisiana Legislative Auditors (LLA) non-compliance list.
the organization operates without discrimination in regard to all persons and complies with all requirements of law and regulations respecting non-discrimination and equal employment opportunities with respect to its officers, staff, employees and volunteers.
we acknowledge that solicitation of charitable donations through payroll deduction is only allowed during the annual campaign period, or other time periods indicated by the State of Louisiana.
we acknowledge that LA SCCC solicitation materials must be provided by the PCFO.
we acknowledge that the Division of Administration shall accept or reject the certifications of a charitable organization.
we acknowledge that if our charitable organization ceases its operations or merges with another organization, it shall be ineligible to receive donations from the LA SCCC.
we acknowledge that OSUP, in coordination with the Division of Administration’s Commissioner’s Office, may remove a charitable organization from the LA SCCC for violating the provisions of the Rule, other applicable provisions of law, or any directive or instruction from OSUP.
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Chief Executive Officer (CEO), Chief Professional Officer (CPO) or Executive Director (ED):* This field is required.(Top management personnel for the organization named in question #1. Application and final campaign results will be mailed to this contact using the mailing address provided below.)
Full Name
Mailing Address (Street, City, State, Zip)
Title
Telephone Number
E-mail Address
Date of Application Review and Signature of Approval
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CEO/CPO/ED Approval:* This field is required. By my signature, I certify that this application is accurate and complete.
Clear
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Volunteer Board Officer (Approving Application):* This field is required.(must be a current board officer)
Full Name
Title
Date of Application Review and Signature of Approval
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Volunteer Board Officer Approval:* This field is required. By my signature, I certify that this application is accurate and complete.
Clear
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Attachment H* This field is required.Required 2021 LA SCCC Application Fee (non-refundable). Please complete this section once CEO and Board Officer Approval has been received and all information is ready to be submitted.
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2021 LA SCCC application fee ($250)
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Organizational Name
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Billing E-mail Address* This field is required.Please provide an e-mail address for payment receipt notifications.
example@example.com
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Thank you for applying to be a part of the 2021 Louisiana State Combined Charitable Campaign (LA SCCC).

As part of the review process, information may be requested (via e-mail) to certify eligibility. Failure to furnish information within 10 days of request constitutes grounds for the denial of eligibility. The burden of demonstrating eligibility shall rest with the applicant.

Notification of Outcome of Application Review:

Letters will be mailed by the Louisiana Division of Administration no later than June 30, 2021, to the Chief Executive Officer (CEO), using the CEO mailing address provided within this application.

If you have any questions, please feel free to call 225-218-2613 or e-mail sccc@launitedway.org.
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