Re-application Form for Participation in the 2018 COMECC Campaign

Category: Unaffiliated organization Federation

Individual organization under a Federation (Federation affiliate)

Region(s): Region 1: Essex, Middlesex, Norfolk, and SuffolkCounties

(check all Region 2: Barnstable, Bristol, Dukes, Nantucket and PlymouthCounties

that apply) Region 3: WorcesterCounty

Region 4: Franklin, Hampden and HampshireCounties

Region 5: BerkshireCounty

Please note that organizations will be listed by their incorporated names only.

Pursuant to the provisions of Governor’s Executive Order No. 451,

REQUIRED:

(Name of organization)

hereby reapplies for participation in the 2018 Commonwealth of Massachusetts Employees Charitable Campaign (COMECC).

In order to be considered a Federation, an entity must have no fewer than ten eligible, participant organizations as members. Include a list of member organizations, as they are toappear in the brochure, with this application.

Please type or print the following information:

All COMECC correspondence will be sent to this Contact person

Contact Person: ______

Contact Telephone: (______)______

Contact E-Mail:______

Contact Address:______

Check this box if the above information is DIFFERENT from the 2017COMECC application:

Telephone (for Brochure): ( ____ )______

Website Address (for Brochure): ______

Disbursement Address:

(ONLY IF DIFFERENT from Contact Address) This is the address where checks will be sent.

If you are an Unaffiliated organization or a Federation, PLEASE EMAIL a 25-word description file in xls or xlslx format using the format on our website (), to . Please have COMECC 2018 and your organization name as the spreadsheet file name, and in the Subject line of the email you are attaching it to.

Federation affiliates, send your 25-word description xls(x) file to your Federation ONLY.

Please refer to Instructions for 25 word xls file_2018 on our website ()

If a Federation is reapplying with new members, each new member organization must supply a NEW application with full documentation. The Federation’s 25 word description file should list themselves first, then each member agency in alphabetical order.

We hereby reapply for participation in the 2018 Commonwealth of Massachusetts Employees Charitable Campaign (COMECC). I certify that there have been no substantial changes to this agency’s programs and services within the region in the past year except as noted on this form. I certify that the programs and services provided continue to serve residents within the designated regions.

If a Federation, I certify that there have been no substantial changes in any of the listed agencies’ programs and services during the past year except as noted on this form. I certify that the programs and services of the listed agencies continue to serve residents within the designated regions.

For question 1, place a check in the appropriate box andlist your actual percentage of fund-raising and administrative expenses to the tenth (e.g. 15.7%): Please review the below before answering.

IRS Form 990 AND 990EZ requirements:

If you file a Form 990: We need a copy of your page 1, and page 10, Part IX, Statement of Functional Expenses.

If you file a Form 990EZ: We need a copy of page 1 of your 990EZ and page 1, and page 10, Part IX, Statement of Functional Expenses of your Pro forma 990 (as explained below).

Mark these copies“Exhibit 1.”

Using the 2015 or 2016IRS Form 990, this fund-raising and administrative expensepercentage shall be computed from information on the IRS Form 990 by addingfrom Part IX, page 10, the amount spent on “Management and general expenses” (line 25C) to “Fundraising expenses” (line 25D) and dividing the resulting total by page 1, Part I, “Total revenue” (line 12-Current Year).

If your organization fills out anIRS Form 990EZ, you must calculate your Administrative and Fund-raising expenses by filling in a Pro forma IRS Form 990.

Pro forma IRS Form 990 Instructions – The IRS Form 990 (long form) can be downloaded from the IRS website ( You, or an accountant, will need to fill in the following section of the Form 990, to be able to calculate your actual percentage of fund-raising and administrative expenses is needed below in question 1.

From your Pro forma 990, page 10, Part IX, (Statement of Functional Expenses):

Add the amount spent on “Management and general expenses” (line 25C) to “Fundraising expenses” (line 25D).

Divide that resulting total by page 1, Part I, “Total revenue” (line 12-Current Year).

(Your Form 990EZ, page 1, Part I, “Total revenue” (line 9) should agree with Pro forma page 1, Part I, “Total revenue” (line 12-Current Year))

List percentage to the tenth of a percent (e.g. 15.7%).

1A)I certify that the organization named in this application in the immediately preceding year has spent 25 percent or less of its total support and revenue on administrative and fund-raising expenses. The actual percentage of administrative and fund-raising expenses is _ _ . _ %.

OR,

1B) I certify that the organization named in this application in the immediately preceding year has spent in excess of 25percent of its total support and revenue on administrative and fund-raising expenses. The actual percentage of fund-raising and administrative expenses is _ _. _ %and that figure is reasonable under the circumstances. (Include as “Exhibit A” detailed justification of the organization’s administrative and fund-raising expenses and a detailed plan to reduce expenses to 25 percent in the next fiscal year.)

Attach a photocopy of Certificate for Solicitation (from the office of the Attorney General of Massachusetts) with an end date of May 31, 2016 or after. Mark this copy “Exhibit B.”

A Federation, Federation affiliate, or Unaffiliated organization may be listed in all regions where it provides services.

Name of organization:in region number(s): (see list top of page 1)

A Federation affiliate may only be listed by one Federation.

Name of affiliate:Name of Federation:

All reapplications shall submit the following documentation:

1. If you file a Form 990: Copy of your page 1 and 10.

If you file a Form 990EZ: Copy of page 1 of your 990EZ AND page 1 and 10 of your Pro forma 990.

Mark these copies“Exhibit 1.” (This is a requirement for ANY 2018 application).

2. If the organization’s actual percentage of fundraising and administrative expenses is more than 25 percent, include a detailed justification and plan to reduce expenses to 25 percent or less in the next fiscal year. Mark this as “Exhibit A.”

3. A photocopy of Certificate for Solicitation (from the office of the Attorney General of Massachusetts) with an end date of May 31, 2016or after. Mark this copy “Exhibit B.”

4. Current list of names and addresses of board members. Mark this list “Exhibit C.”

5. Signed copy of Massachusetts’ non-discrimination policy, found on the Resources/Application page of our website, MUST BE ON ORGANIZATION LETTERHEAD AND SIGNED BY EXECUTIVE/PRESIDENT/OFFICER There are 2 versions: one for Non-religious non-profits, and the other for Religious non-profits. Mark this copy ”Exhibit D”. REQUIRED FOR 2018

6.Electronic version of the 25 word description file in Excel (either .xls or .xlsx) format.

Please have COMECC 2018 and your organization name as the spreadsheet file name, and in the Subject line of the email you are attaching it to.

I attest that no significant change has taken place within this Individual organization, which would deem it, or if a Federation, the Federation itself and the participant member organizations within the Federation, ineligible for participation in the 2018 COMECC, except as noted on this form.

Signature of agency head:

______Date:______

This application and its fourmarked exhibits, and its electronic version of the 25 word description file in xls format, shall be submitted by each Unaffiliated organization and by eachfederated agency (Federation), which is responsible for sending in paperwork for themselves and each of that Federation’s eligible member agencies (federation affiliates).

All reapplications will be reviewed by the Statewide Campaign Manager who shall chair a Statewide Review Committee comprised of the Local Campaign Managers. If the Statewide Review Committee requests additional information or supporting documents to verify information supplied in the reapplication form, the Individual organization/Federation must comply within seventy-two (72) hours of the request.

Completed reapplication form(s) and supporting documentation

(INCLUDING the electronic version of the 25 word description file in xls or xlsx format)

must be received no later than Friday,March 10,2017, 5:00 PM local time.

If you are a Federation affiliate,

send your application (and attachments) and 25 word description spreadsheet file

only to your Federation!

If you are an Unaffiliated agency or a Federation,

send your 25 word description spreadsheet file to:

and your application (and attachments) to:

COMECC Campaign

Attn: Tim Palmer

Action for Boston Community Development

178 Tremont Street

Boston, MA 02111

Questions:

Phone: 617-348-6228

Email:

COMECC Statewide Campaign Manager: Tim Palmer, 617-348-6228,