Arts & Business Council of Greater Boston, Inc

Arts & Business Council of Greater Boston, Inc.

APPLICATION FOR FISCAL SPONSORSHIP

Please fill outthis application as completely as possible and return it to:

Arts and Business Council

c/o VLA

15 Channel Center Street – Suite 103

Boston, MA 02210

Today'sDate:______

Name of Organization/Project: ______

Name and Title of Person filling out application: ______(primary contact person)

Address: ______

(City)(State)(Zip Code)

Daytime Phone: ()Evening Phone: (______)______

Email address: ______

PART I - GENERAL INFORMATION

Describe your organization's purpose and activities:

Are you an incorporated organization? Yes______No______

Which State?______

What is your current status?______

Has your status ever been revoked? Yes______No______

Are your filings currently up to date? Yes______No______

PART II - FINANCIAL INFORMATION

What is your organization's approximate budget for this year? Please also attach budgets for the previous year (if applicable) and for the current year.

$______

Do you have a bank account? Yes______No______

Under the name of: ______

Have you received fundingthis year? Yes______No______

From Whom?

______$______

Part III: Organizational Infrastructure

A.Accounting Assistance

Please state the name and phone number of any person who will be providing accounting/financial assistance.

______

Please describe that person's experience working with tax exempt organizations. (It is not necessary that this person be a C.P.A., but it is necessary that he/she be familiar with the I.R.S. rules and regulations relating to not-for-profit organizations.) ______

______

B.Fundraising Assistance

Please elaborate on your organization's expected revenue sources in the budget you prepared for question 23 of this Questionnaire.

______

Who will be writing the grant proposals and what experience does that person have in fundraising? Is there any particular reason for your group to believe that it will receive particular funding if and when it obtains tax exempt status?

______

Part IV: Budget

Fiscal Year: From ______to______

RevenueYear 1Year 2Year 3Total

Gifts, grants and contributions

Membership fees

Gross receipts from programs or services offered by the organization

Gross investment income

Other

Total Revenue:

Expenses

Fundraising expenses

Amounts distributed for charitable purposes

Compensation of directors and officers

Other salaries and wages (including fringe benefits)

Occupancy costs (rent, utilities, telephone, etc.)

Program/services expenses

Other

Total Expenses:

Please list your Current Assets and Liabilities for the most recently completed Tax Year:

Current Assets

Cash

Net Accounts Receivable

Inventories

Bonds and Notes Receivable, Corporate Stocks, Loans Receivable, or Other Investments (attach and itemized list)

Land

Other

Total Assets:

Current Liabilities

Accounts Payable

Contributions, gifts, grants, etc. payable

Mortgages and notes payable (attach an itemized list)

Other

Total Liabilities:

Have there have been significant changes to your assets and liabilities since the end of the above period? If Yes, please describe:

* If you listed gifts, grants, and contributions in the above chart, provide the names of the expected contributors, if known, and the amount each might contribute each year.

* If you listed program/service revenues in the above chart, provide the names of the expected payors and the amount each might pay each year.

* Do you expect to receive a large contribution from any particular individual, business, or private foundation? If yes, describe:

* What kind of disbursements do you anticipate making through our services? At what frequency? (Example: invoices for services rendered, approximately 10 times per year; or, quarterly operational expenses)

PART V -CERTIFICATION

I hereby affirm that the information contained in this application, or attached to it, is correct, and to the best of my knowledge, complete.

______

Signature Date