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IRS ADMIN FORM Powered By Docstoc
					                    Please find TrustAfrica’s IRS and Organization Information Form.

  The form is an Affidavit containing information requested of foreign organizations that do not have
          section 501 (C ) (3) Determination Letters from the U.S. Internal Revenue Service.

 TrustAfrica also follows the U.S. Executive Orders and laws that prohibit the provision of funding or
other resources and support to organizations and individuals associated with terrorism, such as those
organizations and individuals on terrorist-related lists promulgated by the U.S. Government, the United
 Nations, and the European Union, or associated with the organizations or individuals on those lists.
   Accordingly, TrustAfrica will be making various anti-terrorism checks based on the information
  submitted in this form. TrustAfrica will not share any non-public information obtained through this
    form with anyone outside of the application and grant-making process without the applicant’s
                             permission except as may be required by law.

In accordance with the laws of the US IRS, TrustAfrica can make a grant to an organization only if it meets the
following criteria:

           o   It is organized and operated exclusively for charitable purposes;

           o   No part of its income inures to the benefit of any private individual;

           o   No substantial part of its activities consists of carrying on propaganda or otherwise attempting to
               lobby with the view to influence legislation;

           o   It does not participate in, or intervene in, political campaigns on behalf of any candidate for
               public office; and

           o   If a school, it operates pursuant to a racially nondiscriminatory policy as to students.

To assist TrustAfrica to determine whether your organization meets the above criteria, and whether it is the
equivalent of a public charity under the U.S. Internal Revenue Code, please (1) complete all the questions
below; (2) attest to the answers by signing the bottom of the final page; and (3) attach any of the following
documentation that applies to your organization. If these documents are not in English, TrustAfrica will bear the
cost of translating the document. Please submit your forms as they are.

           o   Charter
           o   By-Laws/ Constitution
           o   Statutes
           o   Articles of Incorporation
           o   Other documents pursuant to which the organization is governed

Name of organization _____________________________________________________________
Please list, with English translations as necessary, all names previously used by the organization (not already
listed above), including all the names used by any organization(s) from or through which the current
organization was created:

     The organization was created                        In what city and country
     by (identify statute, charter,                     was the organization
     etc.)                                              formed?

Who Provided the Initial Funding?

      Is the organization legally registered or licensed with any
                                                                           No           Yes
      government entity?

Please list all current business locations of the organization (other than listed above), including address and
phone numbers (if more than five, list only the five most important business locations):

     The organization is operated exclusively for charitable
     purposes:                                                           No            Yes

 If yes, please provide additional detail and submit copies of the related certificates or documentation of the
registration or license with this form. If not, has an application by the organization for any government
registration or licensing been rejected (and, if it has, explain).

      Does the organization make annual or regular filings with any
      government entity that are publicly available?                      No            Yes
      [If so, please provide copies of the most recent filings.]

Please list all countries where the organization has been active or had any presence, or where it plans to be
active or have a presence:

Please give a brief description of the specific activities that the organization has conducted, is now conducting
and is planning to conduct:

        Does the organization attempt to influence legislation, by
        propaganda or otherwise?                                            No         Yes

       If yes, please explain the nature and extent of such activities:

        Does the organization participate or intervene in (including
        the publication or distribution of statements) political
        campaigns on behalf of, or in opposition to, any candidate for
        public office?                                                      No         Yes

If yes, please explain the nature and extent of such activities.

       Does the organization permit any of its income or assets to be
       distributed to, or applied for the benefit of, a private person or
       non-charitable organization other than pursuant to the conduct
       of the grantee organization’s charitable activities, as payment
                                                                            No          Yes
       of reasonable compensation for services rendered, or as
       payment of the fair market value of property purchased by the

This information may be contained in the organization’s charter, bylaws, or other governing document. If not,
please attach a copy of any legal document (or an opinion of legal counsel) dealing with this matter.

        Does the organization have any shareholders or members
        who have a proprietary interest in the income or assets of the      No          Yes

        Does the organization have any shareholders or members
        who have a proprietary interest in the income or assets of the
                                                                            No          Yes

If yes, list the names of such shareholders or members and the nature of their interest.

Please complete for the organization’s top five executive officers and, if different, the names of titles of heads
of each separate office or location of the organization (add more rows if necessary):

Name                  Position           No. of          Phone             Email
                                        Years of

      Is the organization controlled by or operated in connection with
      any other organization?
                                                                              No           Yes

If yes, please list the names[s] of organization[s] and the nature of such control or connection.

       In the event that the grantee organization were to be liquidated
       or dissolved, are all its assets required to be distributed to
       another not-for-profit organization for charitable, religious,
                                                                             No           Yes
       scientific, literary, or educational purposes, or to a government

This information may be contained in the organization’s charter, bylaws, or other governing document. If not,
please attach a copy of any legal document (or an opinion of legal counsel) dealing with this matter.

If your organization is not an educational institution, a church, or a hospital, please attach a
financial schedule of support for the organization’s four most recently completed taxable years
showing (for each year and in total). SEE ATTACHMENT.

       [A]                         gifts, grants, and contributions received;
       [B]                         membership fees received;

       [C]                         gross receipts from admissions,
                                   merchandise sold, or services performed;
       [D]                         gross income from interest, dividends,
                                   rents, and royalties;
       [E]                         net income from business activities
                                   unrelated to the organization’s exempt
                                   purposes; and
       [F]                         the value of services or facilities furnished
                                   by a governmental unit without charge.

If the organization is an educational institution, hospital, or church or church-related organization, please
answer the appropriate questions below and supply a narrative response if applicable. In addition, please
attach copies of any descriptive materials, such as catalogues or published brochures, which deal with the
organization’s particular function:

1.     If an educational institution:

       If it an organization described by Section 170(b)(1)(A)(ii) of
       the Internal Revenue Code that has adopted and operates
       pursuant to a racially nondiscriminatory policy as to students,
       as set forth in Rev. Rul. 71-447, 1971-2 C.B. 230, and Rev.        No         Yes
       Rul. 75-231, 1975-1 C.B. 158, and as implemented in Rev.
       Proc. 75-50, 1975-2 C.B. 587?

       Is the primary function of the organization the presentation of
       formal instruction?
                                                                          No         Yes

       Does it normally maintain a faculty and curriculum?
                                                                          No         Yes

       Does it normally have a regularly enrolled body of pupils or
       students in attendance at the place where its educational         No           Yes
       activities are regularly carried out?

       If a hospital:
                                                                         No           Yes
       Is the principal function of the organization the provision of
       hospital and medical care?

       If a church or church-related organization:
                                                                         No           Yes
       Does the organization conduct religious worship?

To what extent is the organization connected with or controlled by a church?

                                            B. Financial Information

      3.Organizational Budget                             4. Organizational Budget
      (Current Year)                                      (Last Year)

Fiscal year of organization ends:

      5. Does the organization have a formal system in place for
                                                                          No           Yes
      tracking all receipts and expenditures of funds?

 Please list all governmental agencies not identified that have provided grants or other funding or formal
support to the organization in the current year and the past two years:

        Does your organization itself make grants or donations to
                                                                        No           Yes
       other entities?

If yes, please list top 5 recipients over the past two years, including contact names and addresses:

The undersigned officer attests that the foregoing statements and documents attached hereto are
complete and accurate:

Date: ____________


                               Name of organization (exact legal title)
By: ________________________________________________________

Title: ______________________________________________________


Attest: _______________________


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