Application for Funding - Choose Life Mississippi

Legal Name of Agency

DBA Name

Agency Code

Mailing Address

Physical Address

Telephone

Hotline

Business Line

Fax

Email address

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Board of Directors: Please provide Name, Email, Telephone for each member.

President

Vice President

Secretary

Treasurer

Executive Director

Member 1

Email 1

Member 2

Email 2

Member 3

Email 3

Member 4

Email 4

Member 5

Email 5

Member 6

Email 6

Discrimination Policy

Yes No Does your agency comply with the requirement that recipients of services not be discriminated against for any reason, including, but not limited to race, family status, color, religion, national origin, handicap or age?

Tax Exempt Status

Yes No Has there been a change in your tax exempt status?

Religious Status

Yes No Are you a ministry of a religious organization? If, so please list name, address, and phone of contact organization.

Religious Contact Info

If Applicable

Hours Open

What are your hours of operation?

Alternate Phone Contact

If available, please list a number besides the office where the director can be reached after hours.

Volunteers

How many volunteers do you have?

Training

How often do you have volunteer and board training?

Types of Services

What services do you provide?

Free Services:

Yes No Do you acknowledge that your agency offers free services to women and families to help them choose life for their unborn children.

Abortion:

Yes No Do you acknowledge that your agency is not associated with abortion activities, including counseling for or referrals to abortion clinics, providing medical abortion-related procedures, or pro-abortion advertising?

Additional Information

Use space below to include any additional information you would like to share about your agency.

Federal Form 990

Yes No N/A Federal Form 990 (most recent). If extension has been filed please send copy of extension then submit copy of 990 when completed.

Form 990 Upload

Registration Certificate

Yes No N/A Copy of most recent confirmation of registration certificate from Secretary of State’s office

Registration Upload

Yes No N/A If religious organization copy of letter of exemption from registration from Secretary of State

Exemption Upload

Ministry Registration

Yes No N/A If you fall under the umbrella of a local church and are not required to register with the Secretary of State’s office, please send letter from church stating you are part of their ministry and not required to register if you do not have a letter of exemption.

Ministry Upload

New Year Budget

Yes No N/A Copy of New Year budget

Budget Upload

Financial Statement

Yes No NA Financial Statement (Audited copy if receipts over $500,000.00)

Fin Stmt Upload

IRS Tax Excempt Letter

Yes No N/A Copy of tax exempt letter from IRS

IRS Letter Upload

Criteria for Funding Checklist

Yes No N/A Copy of criteria for funding checklist

Criteria for Funding Checklist

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