Information Requested Of A Proposed Grantee That Is A Foreign Organization Not Having A Section 501(c)(3) Determination Letter From The U.S. Internal Revenue Service The Blue Moon Fund, Inc., as a private foundation under U.S. internal revenue laws, can make a grant to a foreign organization that does not hold a Section 501(c)(3) determination letter from the U.S. Internal Revenue Service only if the grantee meets the following four criteria: * The grantee is organized and operated exclusively for charitable, scientific, religious, literary, or educational purposes; * No part of its income inures to the benefit of any private individual or organization; * No substantial part of its activities consists of carrying on propaganda or otherwise attempting to influence legislation; and * It does not participate in, or intervene in, political campaigns on behalf of any candidate for public office. The information and documentation requested below will assist the Fund in determining whether your organization meets the above criteria. We regret having to ask you to furnish us with so much detailed information, but ask you to understand that we are bound by the relatively technical requirements of the United States Internal Revenue Code. Attached to this questionnaire are schedules which you may wish to use in furnishing the financial information requested in paragraphs 14, 16 and 17 of Part I. Additional sheets may be attached if the space provided below is inadequate. To aid you in the preparation of the certain schedules, the Fund has provided detailed instructions which you will find below: PUBLIC SUPPORT SCHEDULE INSTRUCTIONS You must provide the Fund with the information requested on the Public Support Schedule and the Major Donor Support form, unless your organization is a school or university, hospital, church, or governmental agency. For these, the financial forms are not required. They are a requirement for all other public charities. This form or "schedule" will enable the Fund to determine whether or not your organization meets the IRS definition for a publicly supported charity. Under U.S. law, a charitable organization is considered to be publicly supported if it meets certain conditions referred to as the "public support test." Ideally, a charitable organization's public support (meaning revenues from public sources) must be at least one-third
(33.3 percent) of its total support. If your organization does not meet the requirement that at least 33.3 percent of its total support comes from public sources, it may still be considered for a grant if it meets other criteria, as determined by an IRS "facts and circumstances" test. If this situation should arise, the Fund's staff will provide you with further instructions. In completing the form, please use actual fiscal year figures from the most recently completed four-year period, not projected figures. (if your organization is less than four years old, provide actual figures for all the years of its existence.) For example, if you are filling out the form in 2006, your figures for 2002 should go in column (a), 2003 in column (b), 2004 in column (c), and 2005 in column (d). Write the year at the top of each column. Totals go in column (e). Do not fill in columns (f) and (g). The Fund will complete these columns for you. The Public Support Schedule divides your sources of revenues into six categories: Line 1. Gifts, grants, and contributions. These are voluntary payments or donations to your organization for which no material product or services are given to the contributor, although services might be provided to others (such as the general public). You should also include on this line gifts other than cash (such as free rent, equipment, materials, or supplies) at the fair market value at the time the items were donated. Non-cash gifts from a governmental agency, however, are not included here. They belong on Line 6. The value of volunteer services cannot be included here or elsewhere. Other Line 1 examples include: a grant like the one you are applying for from Fund; a contribution from a corporation or individual; a cash grant from the government to support your organization's general purposes, or to support a specific program or research project; lottery money, whether or not from the government; and revenue from taxes levied by the government on behalf of your organization. Line 2. Membership fees. If, for the purpose of general support, your organization charges membership dues or accepts a donation of some kind from its members, those membership dues should be reported on this line. If members receive something of value or receive a material or substantial benefit, that amount should be subtracted from the amount you report as membership fees. For example, if your organization charges members $10 per year and only provides a periodic newsletter, the entire $10 would be considered dues. If you provided a guide to membership services worth $4, then only $6 would be considered membership dues.
2
Line 3. Program service revenue related to your charitable purpose, such as: All payments received from admissions to events such as conferences, seminars, and workshops. Merchandise sold by your organization relating to its charitable purpose. A portion of membership dues, If, for their $10 membership payment, members received a guide to your services worth $4, the $4 would be program service revenue. Fee for services related to your charitable purpose. If your organization's purpose is to provide legal services to low-income people for a small fee, that fee is considered program service revenue. Fee for services performed for a governmental agency for the direct benefit of the government agency and not the general public. Rental income, if it relates to your charitable purpose. Interest from a revolving loan fund operated by your organization as part of its charitable purpose. Line 4. Interest, dividends, rents, and royalties. Interest income and rental income that are related to your charitable purpose belong on line 3. But here on line 4, include any interest, dividends, rents, and royalties that are not directly related to your charitable purpose. For example, if your organization has a bank account that earns interest income, that income should be recorded here. (Note: A capital gain or loss that you have when you sell investments or other capital assets should not be included on the Public Support Schedule at all.) Line 5. Income unrelated to your charitable purposes. Include all net income from business activities that you regularly perform that are not related to your charitable activities. Net income is total income minus the expense of producing that income. For example, if you operated a bookstore whose operations were not considered part of your charitable purpose, the net income would be included here. Money made on currency exchange gain would also be considered unrelated income. Line 6. Governmental services and facilities. Include the fair market value on the date you received services or facilities given to you, free of charge, by the government or a governmental agency. Do not include services or facilities if they are also available at no charge to the general public.
3
Line 7. Total. Calculate the total for each column, (a) through (e). Next, subtract the number in box 3(e) from the total in box 7(e). Enter this new figure in box 7(g). Line 8. Calculate 2 percent of the amount in box 7(g) and enter it here. Also enter this figure at the top of the Major Donor Support form. Leave the rest of the Public Support Schedule blank. The Fund will complete it for you. MAJOR DONOR SUPPORT FORM INSTRUCTIONS On Line 8 of the Public Support Schedule, you entered a figure that represents 2 percent of your organization's total support. Enter this number again in the blank at the top of the Major Donor Support form. Complete this form for any contributions your organization received from one source which are over this 2 percent figure for the fouryear period. List the complete name of the contributor. Identify what type of organization or individual made the contribution. A key is provided at the top of the form to help you classify your contributions. All contributing organizations should be assigned a number between 1 and 6 based on this key. Enter the number in the column marked "KEY." Number 5, "publicly supported organizations," refers to contributions to your organization by churches, schools, medical institutions, or organizations that can show that a significant portion of their revenues comes from gifts or contributions from a wide cross-section of the general public, rather than from one person, one company, or one family. For each donor, enter the amount of support for each of the last four years in columns (a) through (d). In column (e), enter the total for each donor over the four years. Leave columns (f) and (g) blank. The Fund will complete these columns for you.
4
PART I. 1. Is your organization organized as a corporation under the laws of your country? Yes________ If no, what is the form of the organization? No________
On what date was your organization first organized?
2.
Please attach a copy of the following documents (along with certified English translations of same, if written in another language) , including any amendments thereto: (a) charter, decree, legislative act or similar document under which the organization was created; (b) if not stated in the foregoing document, the document which states the purpose or purposes for which the organization was organized; and (c) the organization's by-laws or constitution.
3.
Is the organization exempt from taxation in your country? Yes________ No________
If yes, please attach a copy of the legislative act or statute, or the sections thereof (along with a certified English translation of same, if written in another language), granting exemption to this type of organization and appropriate documentation (preferably a written statement from the appropriate taxing authority) establishing that this particular organization is tax exempt under the applicable provisions of such act or statute. 4. Are contributions to the organization deductible for income tax purposes under the laws of your country? Yes________ If no, please explain: No________
5
5.
Please give a brief description of the specific activities that the organization is now conducting and planning to conduct:
6.
Does the organization engage in any broad scale solicitation of funds from the general public? Yes________ No________
If yes, please state the nature and extent of such activities.
7.
What percentage of your support is derived from the United States?
8.
Does the organization carry on propaganda or otherwise attempt to influence legislation? Yes________ No________
If yes, please state the nature and extent of such activities.
9.
Does the organization participate in, or intervene in political campaigns on behalf of or in opposition to any candidate for public office (including the publishing or distribution of statements)? Yes________ No________
If yes, please state the nature and extent of such activities.
6
10.
Does any part, or does the organization plan to have any part, of its assets or income inure to the benefit of private individuals? Yes________ No________
11.
If in any year the organization's receipts exceed its expenditures, is the organization required to apply such excess receipts in furtherance of its stated purposes? Yes________ No________
This information may be contained in the documents under 2 above; if not, please attach a copy of any legal document dealing with this matter. 12. Please list below the names and addresses (and titles if appropriate) of the organization's officers and the members of its Board of Directors or similar governing body:
13.
Does the organization make any payments to the above listed individuals other than as reasonable compensation for services rendered, including reimbursement for expenses? Yes________ No________
If yes, please state the amount and purpose of such payment.
14.
Please list below the names of any organization (other than governmental units) or individual, together with all of their respective family members, from which the organization has received two percent (2%) or more of its support during the past four (4) fiscal years of the organization ("Major Donor"). (If the organization has been in existence less than four years, please respond as to each of the fiscal years of the organization since its inception.) [You may use the Public Support Schedule and Major Donor Support forms attached to this questionnaire]
7
15.
For each person or organization listed in response to the question in paragraph 14, list the dates and amounts of support provided by them along with their relationship, if any, to your organization's officers and or Board of Directors (or similar governing body).
16.
State the total amount received as contributions, grants or as payments during each of the past four (4) fiscal years of the organization from all individuals and organizations other than the following: those listed as Major Donors in paragraph 14; members of the Major Donor's families; and any organization (corporation, partnership, trust, etc.) in which they (the Major Donors) hold an aggregate ownership interest of more than 35%:
17.
State for each of the past four (4) fiscal years of the organization (or if the organization has been in existence less than four years, for each of the years since its inception) the total amount of support received from all sources (including Major Donors), separated as follows: (a) (b) (c) (d) (e) gifts, contributions and grants, membership fees, gross receipts from the performance of your organization's religious, charitable, scientific, literary, and educational activities, interest, dividends, rents, and royalties, and other sources (please itemize).
[You may use the Public Support Schedule form attached to this questionnaire] 18. Upon dissolution, are the assets of the organization required to be distributed for charitable, educational, scientific, religious or literary purposes? Yes________ No________
This information may be contained in the documents supplied under paragraph 2, above; but if it is not, please attach a copy of any statute, governmental regulation, or court decision concerning this matter.
8
19.
Please attach a financial statement (a certified English translation, if written in another language) showing assets and liabilities and receipts and expenditures of the organization for the last four years (or if the organization has been in existence less than four years, for the period of its existence). Has your organization ever applied to the Internal Revenue Service of the United States for recognition of exempt status? Yes________ No________
20.
If yes, explain the outcome of that application and the reasons your organization was not determined to be tax exempt by the Internal Revenue Service.
PART II - Relationships with other organizations 21. Is your organization controlled by or operated in connection with any other organization? Yes________ No________
If yes, please list the names of such organizations and the nature of such control or connection.
9
22.
Does your organization operate, sponsor or exercise control over any special projects or programs which might receive support from this grant? Yes________ No________
If yes, please list the projects or programs and furnish answers to the following questions for each:
(a)
Does your organization exercise actual administrative and financial control over the project or program?
(b)
Is your organization legally responsible for the project?
(c)
Does your organization and the project or program have a unified tax return and audit?
(d)
Who on the staff of your organization works directly with the project or program?
(e)
Are any of the project or program's staff also employees of your organization?
(f)
Does your organization regularly monitor and evaluate the project or program?
10
PART III.
For educational institutions or hospitals only
If the organization is either an educational institution or hospital, please answer the appropriate questions below: 23. For educational institutions: (a) Is the primary function of the organization the presentation of formal instruction?
(b) Approximately how large is the teaching staff? Full-time professors and instructors ________ Part-time professors and instructors ________ (b) Does the institution have a regular curriculum? If yes, please submit a catalog, list or description of that curriculum. Yes________ No________
(d) What is the size of the student body in attendance at the place where its educational activities are regularly carried on? Total student body ________ Of this number, how many are full-time students: ________ (e) List the locations (no more than two) at which the student body referred to above attends classes.
(f) Has the institution adopted and currently operates pursuant to a racially nondiscriminatory policy as it relates to students? (A racially nondiscriminatory policy as to students means: The institution admits students of any race, color, and national or ethnic origin to all the rights, priviledges, programs, and activities generally accorded or made available to the students of the institution and that the institution does not discriminate in the administration of its educational, admissions, scholarship, loan, athletic and other institution-adminstered programs.) Yes________ No_______
11
24.
For a hospital: (a) Is the principal function of the organization the provision of hospital or medical care?
12
The undersigned officer affirms that the foregoing statements and the documents attached hereto are complete and accurate.
____________________________________ Name of Organization By: _________________________________ Title: _______________________________ Address: ____________________________________ ____________________________________ ____________________________________ Telephone:___________________________
Sworn to before me this ______ day of _______________, 2____. Witness: _________________________
13