(enter the date here)

(enter your organization’s name and address information here)

Re: Form 990 Questionnaire for Interested Persons

Dear Recipient:

IRS Form 990 now requires us to disclose certain relationships, arrangements, and transactions concerning both conflicts of interest and the independent decision making ofour governing bodies. Before we can provide the required disclosures, we need your help in gathering essential information.

Please complete and sign the attached questionnaire, then return it to us by (enter the date here)byfax or mail.

Fax number: / Mailing address:
(enter your fax number here) / (enter your mailing address here)

We will review your answers to this questionnaire to determine whether any relationships, arrangements, or transactions meet the criteria for disclosure in our Form 990. We will retain your completed questionnaire as part of our Form 990 documentation to substantiate our efforts to accurately make all required disclosures.

To assist you in answering, we have included a list of our officers, directors, trustees, and key employees as Attachment 1 and definitions of various italicizedterms used in the questions as Attachment 2.

Thank you for your assistance.

(enter the signature information for your ED or CEO)

Form 990 Questionnaire for Interested Persons

(enter the name of your organization)
Print Name
Relationship or Position(s) with our Organization

I hereby confirm that I accept your organization’s conflict of interest policy and [check one]

 I have answered NO to all of the questions on the following pages.

 I have answered YES to one or more questions and provided the requested information.

Signature
Date

Family and Business Relationships with Officers, Directors, Trustees, and Key Employees

In answering the following questions, refer to the listof officers, directors, trustees, and key employees provided (Attachment 1).

  1. Did you have a family relationship with any of our organization’s officers, directors, trustees, or key employees at any time during the past calendar year?  Yes  No

If yes, please identify the person(s):

  1. Did you have a business relationship with any of our organization’s officers, directors, trustees, or key employees at any time during the past calendar year?  Yes  No

If yes, please identify the person(s):

  1. Did you receive compensation from a related organization?  Yes  No

If yes, please provide the organizations and amount(s) received:

Organization / Amount

Grants and Assistance Benefiting Interested Persons

  1. Did you or a family member receive any grants or other economic assistance from our organization?  Yes  No

If yes, please provide the following:

Amount of benefit
Type of assistance received
Recipient’s name

Business Transactions Involving Interested Persons

Organizations are required to report business transactions for which payments were made during the tax year between our organization and an interested person―if such payments exceed certain reporting thresholds, and regardless of when the transaction was entered into by the parties.

  1. Did you or a family member have a business transaction with our organization?  Yes  No

If yes, please provide the following:

Name of interested person(s) involved
Person’s relationship to our organization
Amount of the transaction
Description of the transaction(s)
Did you share in the revenue? /  Yes  No

Form 990 Questionnaire for Interested Persons | 1

Attachment 1

As of(enter date here), our organization’s current and former officers, directors, trustees, key employees, and highest-compensated employees are as follows:

(enter names and titles) / (enter names and titles)

Form 990 Questionnaire for Interested Persons | 1

Attachment 2

As of [ENTER DATE], the list of our related organizations is as follows:

[ENTER NAMES AND TITLES] / [ENTER NAMES AND TITLES]

Form 990 Questionnaire for Interested Persons | 1

Attachment 3

Business relationship

Business relationships between two people include any of the following:

  • One person is employed by another person, either in a sole proprietorship or by an organization for which the other person is a trustee, director, officer, key employee, or greater-than-35% owner.
  • One person transacts business, directly or indirectly, with another person―other than in the ordinary course of either person’s business, on the same terms generally offered to the public. Such business involves cash or property transfers valued at more than $10,000, in aggregate, during the organization’s tax year.
  • The two persons are directors, trustees, officers, or greater-than-10% owners in the same business or investment entity.

For these purposes, business relationships do not include the following:

  • Attorney/client, medical professional/patient, priest/clergy, or penitent/communicant relationships.
  • Relationships developed in the ordinary course of business―i.e., on terms generally offered to the public.

Business Transaction

Business transactions include, but are not limited to, contracts of sale, lease, license, and performance of services―whether initiated during an organization’s tax year or ongoing from a prior year. Business transactions also include new and ongoing joint ventures in which the profits or capital interest of the organization and interested persons each exceeds 10%. Contributions or membership dues paid to the organization by its officers, directors, etc. are not considered business transactions.

Family Relationship

Family relationshipsinclude spouses, ancestors, brothers and sisters (whole and half), children (natural and adopted), grandchildren, great grandchildren―and the spouses of siblings, children, grandchildren and great grandchildren.

Interested Person

Interested person refers to an organization’s current officers, directors, trustees, key employees, and five highest-compensated employees――as well as any person who fell under one of these categories within the five years prior to the year currently being reported on.

Grants and Other Economic Assistance

Grants and other economic assistance include awards, prizes, cash allocations, stipends, scholarships, fellowships, research grants, and similar payments and distributions made by our organization.

Economic assistance also includes thegoods, services,and use of facilities provided by our organization during the tax year. It does not include salaries or other compensation to employees.

Form 990 Questionnaire for Interested Persons | 1