West Virginia Development Office

WEST VIRGINIA DEVELOPMENT OFFICE

APPLICATION FOR

THE NEIGHBORHOOD INVESTMENT PROGRAM FISCAL YEAR 2013

ALL APPLICATIONS MUST BE POSTMARKED NO LATER THAN JUNE 29, 2012

APPLICATIONS POSTMARKED AFTER JUNE 29, 2012, WILL NOT BE ACCEPTED

NIP FY2013 APPLICATION COVER SHEET

WV-NIPA # (FOR WVDO USE ONLY):

ORGANIZATION NAME:

ADDRESS:

COUNTY: *REGION #:

*CONGRESSIONAL DISTRICT:

CEO/PRESIDENT:

CONTACT PERSON:

FEDERAL TAX ID NUMBER:

TYPE OF PROJECT:

PROJECT DESCRIPTION:

TOTAL AMOUNT OF CREDIT REQUESTED:

Due to increasing demand for the tax credits, we are encouraging projects to seek no more than $125,000 in tax credit.

*Congressional Districts and Regional Planning and Development Council regions are listed on pages 5 and 6 of the NIP Project Guidelines Section in the Application Guidelines

2 NIP APPLICATION CHECKLIST AND INSTRUCTIONS

Use this checklist as you review and format your application prior to submittal to the WVDO.

ALL PROJECTS MUST INCLUDE THE FOLLOWING COMPONENTS:

Section I: Applicant Information Page Number

A. General Information: organization name, address, contact information, etc. The contact person listed should be an individual at the organization whom the WVDO may get in touch with if additional information is requested, or if any questions arise. Congressional District information is on page 5 of the NIP Application Guidelines.

B. Number of full-time, part-time, and volunteer staff

C. Federal tax I.D. number

D. Total amount of credit requested, total amount of other funding, etc.

Section II: Project Information Page Number

A. Type of project: Please use the definitions outlined in the NIP Application Guidelines (pages 2 and 3) to determine the category your project fits into.

B. In the space provided, summarize the project in one sentence. This will be used by our office as a project description, so please keep the sentence to a reasonable length.

C. In the space provided, tell us how your organization would use donations received as a result of tax credit towards your proposed project.

Section III: Location Information Page Number

A. Project location

B. Name of project area (if applicable)

3 NIP APPLICATION CHECKLIST AND INSTRUCTIONS, continued

Section IV: Contribution Summary Page Number

A. Total estimated contributions: The values entered should be the sum of all anticipated contributions from each classification: cash, personal property, real property, stock, or in-kind services. How much of each type of contribution do you anticipate you will receive as a result of the NIP credit? Use the multiplier to determine the amount of tax credit you will need. Keep in mind:

. In-kind contributions are restricted to services provided by accountants, lawyers, architects, doctors, and other state licensed medical personnel AND these donors must also donate cash, property, or stock in addition to their services in order to be eligible. . There is only $3 million in tax credit to be distributed. Apply for an amount that you feel you can realistically use. Due to increasing demand for the tax credits, we are encouraging projects to seek no more than $125,000 in tax credit.

B. Organization’s fundraising experience: Please be as accurate and descriptive as possible.

C. Past participation in the NIP: Please check your records and complete these questions accurately, as it will save time in processing/evaluating your application.

D. Total amount of all donations (INCLUDING GRANTS OR FOUNDATION MONEY) received in the past two state fiscal years. It is important that we understand how much funding your organization receives in the form of charitable contributions.

E. Would your organization be able to complete your project if you did not receive the full amount of credit requested? When planning your project, please keep in mind that the NIP Advisory Board may allocate an amount of credit that is lower than the requested amount.

4 NIP APPLICATION CHECKLIST AND INSTRUCTIONS, continued

Section V: Attachments Page Number The attachments requested in this section are essential materials for consideration of the applications (with the exception of item H). APPLICATIONS WILL BE CONSIDERED INCOMPLETE IF ATTACHMENTS ARE NOT INCLUDED. Please be brief but thorough when completing the attachments.

A. COPY OF IRS FORM 990

B. COPY OF IRS 501(C)3 DETERMINATION LETTER

C. COPY OF CHARITABLE ORGANIZATION REGISTRATION CONFIRMATION LETTER FROM THE WEST VIRGINIA SECRETARY OF STATE. Please note – just because an organization is incorporated DOES NOT mean that it is registered with the Charitable Organizations Division. If you do not have a letter from the Secretary of State confirming your registration as a charitable organization, and/or you have questions about registering, please contact the Secretary’s office directly at: West Virginia Secretary of State Charitable Organizations Division (304) 558-6000 D. Project Narrative: Address specifically how your project meets each of the NIP criteria detailed in the NIP Application Guidelines (pages 2-5), and provide documentation to support your narrative. For example, if your project will primarily serve low-income persons, provide statistics or other documentation that supports this claim (e.g., statistics showing the percentage of persons served that are low-income in contrast with others served). In addition, please describe the purpose of the project and the problem or issues the project will address. Also describe how you measure outcomes for your project and how outcome indicators are tracked (NIP Application Guidelines, page 7 and 8). MAXIMUM LENGTH: 6 PAGES.

E. Project Schedule: Provide a detailed description of the major project activities, including what will be done, who will complete each activity, and a projected timeline for project completion. Also, provide a description of your fundraising plans including a timeline of any fundraising events/initiatives that will involve NIP tax credit. MAXIMUM LENGTH: 2 PAGES.

F. Annual Financial Statement: Provide a copy of your organization’s most current financial statement.

G. Board Resolution (sample resolution can be found on page 9 of the NIP Application Guidelines)

H. Additional Project Literature: (Optional)

5 6 WEST VIRGINIA DEVELOPMENT OFFICE NEIGHBORHOOD INVESTMENT PROGRAM APPLICATION FORM FISCAL YEAR 2013

Section I. APPLICANT INFORMATION

A. Name: Address:

Congressional District County: (see page 5, NIP Project Guidelines): Telephone: Fax Number: E-Mail Address: Web Address: Chief Executive Officer: Contact Person (if different from CEO) B. Number of full-time staff: Number of part-time staff: Number of volunteer staff: C. Federal Tax ID Number: D. Total amount of credit requested: Total amount of other funding (non-NIP contributions) for the project:

Section II. PROJECT INFORMATION

A. Type of project (See Pages 2 and 3, NIP Application Guidelines). Check all that apply: 1. Neighborhood Assistance Project 2. Community Service Project 3. Crime Prevention Project 4. Job Training or Education Project 5. Other (please specify)______B. Please provide a one-sentence description of the project. Be as specific as possible.

C. How would your organization use donations received as a result of the tax credit?

5 Section III. LOCATION INFORMATION

A. Project Location: County: City/Town: B. Name of area within town/city (if applicable) (example: West Side): C. Census Tract

Section IV. CONTRIBUTION SUMMARY

A. Total Estimated Contributions: Type of Contributions Amount of Contributions Tax Credit Requested Cash $ x .5 $ Personal Property $ x .5 $ Real Property $ x .5 $ Stock $ x .5 $ In-Kind Contributions $ x .75 x .5 $ TOTAL $ x .5 $ B. The NIP requires the participant to solicit donations for the tax credit. Does your organization currently engage in fundraising? If yes for above, describe the organization’s experience in fundraising:

C. Has your organization participated in the NIP before? If so, what year? (check all that apply)

FY1997 FY1998 FY1999 FY2000 FY2001 FY2002 FY2003 FY2011 FY FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 2012

If your organization is a past participant, please complete the following for the year(s) participating:

Fiscal Year Amount Requested Amount Awarded Amount Used 1997 $ $ $ 1998 $ $ $ 1999 $ $ $ 2000 $ $ $ 2001 $ $ $ 2002 $ $ $ 2003 $ $ $ 2004 $ $ $ 2005 $ $ $ 2006 $ $ $ 2007 $ $ $ 2008 $ $ $ 2009 $ $ $ 2010 $ $ $ 2011 $ $ $ 2012 $ $ $

5 Section IV. CONTRIBUTION SUMMARY, continued

D. Please list the total amount of all donations (including grants or foundation money) the organization has received in the past two fiscal years (please use state fiscal year, July 1- June 30):

FY2010 FY2011

Section V. ATTACHMENTS REQUIRED

A. Copy of IRS Form 990.

B. Copy of IRS 501(c)3 Determination Letter

C. Copy of charitable organization registration confirmation letter from the Secretary of State’s Office (Please note, we DO NOT need copies of your Articles of Incorporation).

D. Project Narrative: The project narrative should describe specifically how each of the NIP criteria (set forth in law) will be addressed. See pages 2-5 in the NIP Application Guidelines for details on NIP criteria and pages 7-8 for details on outcome measurement. Maximum length: 6 pages.

E. Project Schedule: A detailed schedule for implementation of the project, including fundraising plans and timeline. Maximum length: 2 pages

F. Annual Financial Statement: A copy the applicant’s most recent annual financial statement.

G. Board Resolution (see page 9 of the Application Guidelines)

H. Optional: You may attach any other literature or narrative describing the program.

All applicants who are approved for participation must send a representative to attend a participant workshop. Approved applicants will be notified of the time and location of the workshop. Failure to attend the participant workshop may result in forfeiture of the tax credits awarded to your organization.

I certify that all statements on this form are true and correct to the best of my knowledge. Furthermore, I understand that no tax credit shall be issued by our project for donations until the project is approved by the NIP Advisory Board and certified by the WVDO.

______Signature of Applicant/Chief Executive Officer Date

5 -IMPORTANT-

FY 2013 Applicants will be notified of their status in August 2012.

If your project is approved for participation in the NIP for FY 2013, you will be required to send a representative to attend an NIP Participant Workshop.

Details on location and time for this workshop will be sent to approved project contacts. 