Neighborhood Investment Program Quarterly Report
September 7, 2012 – December 31, 2012
PLEASE RESPOND BY THURSDAY, JANUARY 31, 2013
Name of Organization:______
Person Responding:______
NIPA#:______Phone Number:______
Total Amount of Credit Allocated to Your Organization:______
Percentage of Credit Issued to Donors (as of December 31, 2012):______
______
Credit Issuance
1. In dollars, how much credit have you issued to donors?
______
2. How much total revenue has this brought to your organization?
______
3. Were any of the credits for contributions of stock?______
4. If yes for questions #3:
a) What was the date of the donation?______
b) Has the stock been sold by the organization?______
If so, when?______
c) If the stock has been sold, please attach verification of the sale of the donated stock
Marketing
1. How many potential donors have you contacted about the credits?
______
2. What type of response are you receiving from potential donors after approaching them about the credits?
______
3. Do you feel you can effectively describe the program to donors?______
4. If no for question #3, in what way could the West Virginia Development Office staff be of assistance?
______
______
______
5. Of the donations received this quarter (those for which you issued NIP tax credit), how many were:
Project Progress and Outcome Measurement
1. In your approved application, you were required to outline outcomes and outcome indicators for your project. What are your project’s outcomes and outcome indicators?
______
______
______
______
2. Using the above outcomes and outcome indicators outlined in your approved application, please apply them to your NIP project as of this quarter:
Project Element / Outcome / Outcome Indicator(s)Example: Free Health Clinic / Uninsured/Underinsured individuals will lead healthier lifestyles / · Number of prescriptions filled
· Number and percent of patients undergoing health screening
· Number of facilities renovated
RE-ALLOCATION REMINDER
The NIP Advisory Board may re-allocate tax credit that has been returned to the West Virginia Development Office. If you have not begun to market your share of credit and are unaware of any potential donors, you should consider the likelihood of your being able to use the credit. If you feel you will be unable to issue all of your tax credit, we ask that you officially inform our office in a separate letter. Your unused tax credit may be of benefit to another participant.
If you have not used at least 70% of your total allocation by the March 15 deadline, you may be required to return between 25% to 100% of your total allocation to the West Virginia Development Office for re-allocation to other projects.
Please fax, mail or e-mail your completed report to the following:
Ellen Vance
West Virginia Development Office
Building 6, Room 553
Charleston, West Virginia 25305
Phone: (304) 558-2234
Fax: (304) 558-2246
E-mail:
You may also obtain the report at the following address:
www.wvdo.org/downloads
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