3. PRIVATE, NON-PROFIT ASSURANCE STATEMENT (REQUIRED FOR
NON-PROFIT ORGANIZATIONS ONLY)
Non-profit organizations must complete the information below, sign and include this
assurance statement with their proposal.
FNS provides an electronic copy of this format at
Check [√] each Assurance Statement
item below to
indicate you have
read and Upon request, my non-profit organization will provide FNS
understand each with:
A copy of the IRS Determination Letter, form 501(c)(3), or proof
of application for exempt status under section 501(c)(3) of the
Internal Revenue Code.
A list of the Board of Directors.
The most recent audit of the organization’s financial records. (If
your organization has not had an audit, a financial statement
signed by the Treasurer of the Board will suffice.)
By signing below, the organization and organization’s representatives certify that the
above assurances are met. If any of the above assurances cannot be met by the
organization to the satisfaction of FNS, the organization may be eliminated from
consideration for a grant. Public organizations are not required to submit the documents
Name and Address of Private, Non-profit Organization:
Name of Authorized Representative:
Signature of Authorized Representative: Date: