STATE OF ARIZONA
STATE EMPLOYEE CHARITABLE CAMPAIGN
CHARITY APPLICATION
CAMPAIGN YEAR: 2011
DESCRIPTION: Independent Charity & Federation Application
APPLICATION DUE DATE AND TIME: April 29, 2011, 5:00 PM, MST.
SUBMISSION OF INQUIRIES: Inquiries regarding this application should be submitted in writing or
email to the Application Contact Person identified below.
APPLICATION DELIVERY/MAILING ADDRESS
Arizona State Employee Charitable Campaign
Ginny Brown, Campaign Assistant
100 N 15th Avenue, Suite 402
Phoenix, Arizona 85007
Applications received by the correct time and date will be opened and logged. Applications must be in
the actual possession of the Arizona State Employees Charitable Campaign Office on or prior to the time
and date, and at the location indicated above. Late Applications will not be considered.
Applications shall be submitted in a sealed package and the Applicant’s name and address clearly
indicated on the package or they shall be submitted via the online application system by April 29, 2011.
Solicitation Contact Person:
Ginny Brown, SECC Campaign Assistant
Phone Number: (602) 542-2755
E-mail: Ginny.Brown@azdoa.gov
DATE: March 3, 2011
________________________
Angela C Fischer
SECC Executive Director
SECC CHARITY/FEDERATION PROFILE FORM
(This form is required for each individual charity regardless if it is
submitted independently or through a federation.)
1. TYPE OF APPLICATION: Independent Charity Federation Charity Federation
2. NAME & CONTACT INFORMATION:
Name of Charity for Donor Guide:
Legal Charity Name:
Street Address: City: Zip Code:
Charity General Phone Number:
Contact Name: Contact Phone Number:
Contact Email Address:
General Email Address: Charity Website:
3. Services Provided (check all that apply):
Health Human Services Environmental
Children Clothing Community Development
Dental Diversity Domestic Violence
Education Emergency Response Employment Readiness
Financial Education Food Homelessness - Shelter
Habilitation - Disabled Legal Services Literacy
Mental Health Youth (teens) Seniors
Other: explain:
4. Administrative Overhead %:
5. 25 word charity description:
6. Services Provided in Which County(ies)/Locations or indicate statewide, national or
international:
Apache Cochise Coconino Gila Graham
Greenlee La Paz Maricopa Mohave Navajo
Pima Pinal Santa Cruz Yavapai Yuma
OR
STATEWIDE NATIONAL INTERNATIONAL
7. Would you like to have your color logo appear beside your name in the SECC list for a $25
handling fee? YES NO
8. Would you like to participate in our speaker’s bureau and be invited by state employees to
speak at SECC donor meetings if requested? YES NO
If yes, to which counties are you willing to travel?
Apache Cochise Coconino Gila Graham
Greenlee La Paz Maricopa Mohave Navajo
Pima Pinal Santa Cruz Yavapai Yuma
STATEWIDE
2011 SECC Soft File Requirements
(This information is required by both individual charities, federations and federation member charities)
Disk and/or email requirements
25 word charity description – provided in Microsoft Word, 10pt Arial font
6 digital pictures that can be used to demonstrate to State Employees how your charity
helps – provided in jpeg, bmp or gif format, 300 dpi
2 true stories on how your charity helped – provided in Microsoft Word, 10 pt Arial font
Optional
1 digital color logo – provided in jpeg, bmp or gif format, 300 dpi
This file must be labeled with your charity name as you would like it to appear in the
campaign donor list. Additionally, a check for $25 must accompany your application.
SECC CHARITY/FEDERATION MEMBER CERTIFICATIONS FORM
(This form is required by both individual charities and federations)
CERTIFICATION STATEMENTS
(If an applicant answers “No” to any of the following certifications, please include an explanation.)
ADMINISTRATIVE CERTIFICATIONS:
A. I certify that the organization named in this application is (and all its member charities are)
recognized by the Internal Revenue Service as tax exempt under 26 U.S.C. 501(C) (3) and to
which contributions are tax deductible pursuant to 26 U.S.C. 170, and further that it has been in
existence as a 501(C) (3) organization for at least three years by the due date of the application
(April 15, 2011).
YES NO
IRS Determination (Attachment A)
If no, please explain:
B. I certify that the organization named in this application is (and all its member charities are)
directed by an active and responsible governing body and whose members have no material
conflict of interest and, a majority of which serve without compensation.
YES NO
List of current board members and the date of the most recent board meeting
(Attachment B)
If no, please explain:
C. I certify that the organization named in this application has (and all its member charities
have) the primary purpose of being a health and/or human, environmental or historical
service delivery organization as defined in Eligibility Criteria #4.
YES NO
Supporting documentation that demonstrates provision of immediate health and/or human,
environmental or historical services (Attachment C)
If no, please explain:
D. I certify that the organization named in this application has (and all its member charities
have) a Direct and Substantial Local Presence as defined in Eligibility Criteria #7.
YES NO Not Applicable
Supporting documentation that demonstrates your local or statewide presence
(Attachment D)
If no, please explain:
E. I certify that the organization named in this application (and all its member charities) prohibit
the sale or lease of the contributor lists, and does not permit payments of commissions,
finder’s fee, percentages, bonuses, or similar practices in connection with its fundraising
activities.
YES NO
If no, please explain:
F. I certify that the organization named in this application conducts (and all its member charities
conduct) publicity and promotional activities based upon its actual program and operations,
that these activities are truthful and non-deceptive, include all material facts, and make no
exaggerated or misleading claims.
YES NO
If no, please explain:
G. I certify that the organization named in this application has (and all its member charities
have) a policy regarding the practice of non-discrimination. It does not discriminate on the
basis of race, color, religion, sex, age, national origin or physical or mental disability against
persons who are served, against employed staff, and against members of the governing body.
YES NO
H. I certify that the organization named in this application is (and all its member charities are)
registered with the Arizona Secretary of State.
YES, provide your ID#
NO, however I have attached documentation that
shows that I have filed an application with the
Secretary of State. I understand that funds will
not be released to me from the SECC if I do not
provide the Secretary of State number.
FINANCIAL CERTIFICATIONS:
I. I certify that the organization named in this application accounts (and all of its member
charities account) for its funds in accordance with Generally Accepted Accounting Principles
(GAAP).
YES NO
J. I certify that the organization named in this application has (and all of its member charities
have) submitted accurate financial documents, IRS Form 990 (minimum of pages 1, 2, & 4)
and/or all relevant notes and supplemental schedules, and that they have matching period
ending dates on or after June 30, 2009 for organizations operating on a fiscal year or
December 31, 2009 for organizations operating on a calendar year.
YES NO
Copy of latest financial statements dated on or after June 30, 2009 for organizations
operating on a fiscal year or December 31, 2009 for organizations operating on a calendar
year. (Attachment E)
Copy of completed IRS Form 990 (not 990A) pages 1, 2 and 4. (Attachment F)
K. If revenue exceeds, $500,000, I certify that the organization named in this application (and its
member charities were) was audited in the immediately preceding year (ending date on or
after December 31, 2009) in accordance with Generally Accepted Auditing Standards
(GAAS) by an independent certified public accountant.
YES NO Not Applicable (revenue under $500,000)
Copy of Certified Public Accountant’s Opinion relating to the financial statements
provided. (Attachment G)
L. I certify that the organization named in this application has expended 25% or less of its total
support and revenue on management & general and fund-raising expenses plus any
association and/or federation fees and costs in the immediately preceding year.
YES NO
Management & General (IRS Form 990, Line 25, (A)
Column C)
Fundraising (IRS Form 990, Line 25, Column D) + (B)
TOTAL EXPENSES (C)
Total Revenue (IRS Form 990, Line 12, Column A) (D)
ADMINISTRATIVE EXPENSE PERCENTAGE (C)\(D)
If your administrative overhead is above 25% please provide a detailed description of the
cause of the overage and your plan to reduce your administrative overhead to the required
percentage by next year.
Explanation:
M. I certify that the organization named in this application meets all known, stated Eligibility
Criteria of the SECC.
YES NO
If no, please explain:
N. I certify that no officers, directors, or affiliated organizations, including subsidiaries, partners,
or parent organizations of the organization named in this application (and none of its member
agencies), support or engage in terrorist or violent activity.
YES NO
If no, please explain:
O. I certify that the organization named in this application (and none of its member agencies
have not) has not or will not provide financial, technical, in-kind, or material support or
resources to any individual or entity, or agent thereof, that we know, or have reason to know,
advocates, plans, sponsors, engages in, or has engaged in terrorist or violent activity,
including prohibited persons on a U.S. Government issued list. Furthermore, this
organization takes responsible steps to ensure that our funds or resources are not used by this
organization or any organization to which these funds or resources may be re-granted,
distributed or processed, to support terrorists or terrorist organizations, including prohibited
persons on a U.S. Government issued list.
YES NO
Signature by authorized official
I, , AM THE DULY APPOINTED REPRESENTATIVE OF THE ABOVE NAMED
ORGANIZATION. By my signature below, I certify and affirm all statements and information enclosed
in this application are true and correct.
Typed or printed name:
SIGNATURE: ________________________________ DATE: _______________
TITLE:
All of the information above is required to be submitted. If any of the above information is unavailable
please email Ginny Brown at Ginny.Brown@azdoa.gov