National Council on Problem Gambling

2014 AFFILIATE MEMBER INFORMATION PACKET AND CHECKLIST

As the primary provider and facilitator of local services, Affiliates are a vital part of the safety net that together we seek to provide. Thank you for all you do on behalf of problem gamblers and their communities. The information you provide in your checklist will help us help you and all our colleagues.

Please return this completed form along with required attachments, postmarked, faxed or emailed on or before Friday, March 31, 2014. Dues are payable by Friday, May 30, 2014. Thank you!

# Required

# AFFILIATE ORGANIZATION NAME ______

# Website: ______# Tax ID EIN #

# DESIGNATED AFFILIATE REPRESENTATIVE FOR 2014-2015: The designated representative should plan to serve for the full year.

______

1. # Representative # Title

______

# Email # Phone Fax

______

2. Alternate Title

______

Email Phone Fax

Very important People

The following information is required pursuant to Section 3.2 of the NCPG Bylaws:

1.  Please list your Affiliate’s current Officers, including address, phone number and email.

Name Address Phone/Email

# President/Chair ______

# Vice President/ Vice Chair______

# Secretary ______

q Check if combined office: Secretary/Treasurer

# Treasurer ______

2.  # Please attach a complete list of your Affiliate’s Board of Directors, including address, phone number and email.

ADDITIONAL INFORMATION requested to help facilitate mutual communications and support.

1.  Please attach a complete list of your organization’s staff and their titles.

2.  Please attach a copy of your most recent annual report or a list of your activities.

Financial Form

Pursuant to Section 3.2 of the NCPG Bylaws, Affiliate members must verify and provide their financial information by attaching one of the appropriate financial forms as indicated below. Complete only one:

1.  # Please enter starting date of your fiscal year ______and ending date ______.

2.  # Copy of the most recent IRS Form 990, 990EZ (postcard) or 999A (as submitted to the IRS by the Affiliate) covering the Affiliate’s most recently completed fiscal year. My form is:

q 990 q 990-PF q 990EZ (postcard) q 999A

1A. Copy of the annual financial statement for the most recently completed fiscal year (applies only to Affiliates who are not required by the IRS to file one of the forms above).

Dues Payment*

1.  # Annual Gross Income: $______

2.  # Dues amount: $______(see schedule below)

3.  Check # ______Enclosed ______Will be sent on ______(due by May 30, 2014)

Please make check payable to “National Council on Problem Gambling.”

I hereby attest that all information provided here is accurate and up to date.

______

#Signature of the Affiliate Representative or Alternate #Date

______

#Signature of the Board President of the Affiliate or equivalent* #Date

*(must be a different person than the first signatory and a member of the Board)

For questions regarding this form, contact Affiliate Committee Chair Wiley Harwell or NCPG Executive Director Keith Whyte. Please return to NCPG at:

National Council on Problem Gambling

730 11th St, NW, Ste 601

Washington, DC 20001

Phone: 202.547.9204

Fax: 202.547.9206

*Dues Payment INFORMATION

Standard affiliate dues are based on the annual gross income (including ‘pass-through’ contributions but not including in-kind gifts) as reported on the most recently submitted Internal Revenue Form 990, 990-PF, 990EZ or 999A or the most recent annual financial statement.

Affiliates that file a 990-PF should calculate their gross income by adding the amounts in Part I, line 12, columns a and b.

Dues are assessed according to the schedule above and are set by the Board of Directors at a minimum of $100 and a maximum of $5,000.

Under extreme circumstances only, an Affiliate may request a one-time reduction of dues by attaching a written statement to this form which describes in detail the circumstances that warrant the reduction. The NCPG Board of Directors will review the request and make a determination whether to authorize the reduction. Under no circumstance will an Affiliate’s dues be reduced below $100.

The deadline to submit this form and supporting documents is
March 31, 2014.

The dues payment deadline is May 30, 2014.
Double-check!

q Name of the Affiliate

q Website

q Tax ID or EIN #

q Names/contact info for Designated Affiliate Rep and Alternate for 2013-2014

q Names/contact info for your Board Officers

q List of your Board Members

q List of your Staff Members and their titles

q Your most recent annual report

q Your most recent 990 or other IRS/federal financial documentation

q Annual gross income (includes everything but in-kind contributions)

q Dues amount

q Dues check #

q Dues payment enclosed or payment date noted

q Signature of the Affiliate Rep or Alternate

q Date

Thank you!