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

or

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

  1. Describe your organization's purpose and activities:
  1. 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Has your status ever been revoked?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

  1. 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.

$______

  1. Do you have a bank account? Yes______No______

Under the name of: ______

  1. Have you received fundingthis year? Yes______No______

From Whom?

______$______

______$______

______$______

______$______

Part III: Organizational Infrastructure

A.Accounting Assistance

  1. 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

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

______

______

______

  1. 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

  1. Gifts, grants and contributions
  1. Membership fees
  1. Gross receipts from programs or services offered by the organization
  1. Gross investment income
  1. Other

Total Revenue:

Expenses

  1. Fundraising expenses
  1. Amounts distributed for charitable purposes
  1. Compensation of directors and officers
  1. Other salaries and wages (including fringe benefits)
  1. Occupancy costs (rent, utilities, telephone, etc.)
  1. Program/services expenses
  1. Other

Total Expenses:

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

Current Assets

  1. Cash
  1. Net Accounts Receivable
  1. Inventories
  1. Bonds and Notes Receivable, Corporate Stocks, Loans Receivable, or Other Investments (attach and itemized list)
  1. Land
  1. Other

Total Assets:

Current Liabilities

  1. Accounts Payable
  1. Contributions, gifts, grants, etc. payable
  1. Mortgages and notes payable (attach an itemized list)
  1. 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