Georgia Community Events & Solutions
Community Events Agency Update
July 2017-June 2018
Agency Name: ______
Mailing Address:______
City, St. Zip code:______
Website:
Staff Contact at Agency Phoneext
(Person who will handle ticket requests)
E-mail Fax
PLEASE PRINT OR TYPE CLEARLY. All information must be completed and returned for continued service. Please fill out completely - our funders require this information.
Primary County Other Counties Served
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Areas of Service – Check all that apply:
____ Mental Health
____ Cognitive Disabilities
____ Substance Abuse/Recovery
____ Developmental Disability
____ Mobility Impairment
____ Blindness/Visual Impairment
____ Deafness/Hearing Impairment
____ HIV/AIDS Services
____ Other Disability:______
_____ Refugee or Immigration Services
____ Offender Rehabilitation
____ Domestic Abuse Services
____ Homeless Facility/Foster Care
____ Low-income Community
____ Other: ______
Which is the primary area of service?
Number of People and Age Groups Served:
______Total number of people served yearly
_____% Seniors (over age 60)
_____% Adults between 19 and 60
_____% Youthbetween 13 and 18
_____% Youth between birth and 12
_____ % Male
_____ % Female
What was your total actual expenses for your last completed fiscal year? ______
What is your total budget for your current fiscal year?______
Indicate % of funding from each source:
City ______%County ______%
State ______%Federal ______%
Private _____%United Way ____%
Religious Organizations ______%
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Is your Agency For Profit? YN
****If yes, please contact the Program Coordinator BEFORE completing this form.
*All updates are sent via E-MAIL. Please ensure that we have a current address and that your system is set up to receive messages from us, including adding us to your address book or whitelist.
NOTE: Be prepared to provide a current (date stamped) 501c(3) letter before we process your payment. The name on the 501c(3) status letter must be the name of your program/agency (i.e., cannot be the name of a church).
*ALL renewals will be vetted through the IRS for a current Form 990. (If you have not filed a current IRS Form 990, your renewal will not be processed.
Agency Description – briefly state the general purpose and goals of your agency – what you do, not your mission statement.
______
______
Demographic info – Our donors require this information from us.
Information Source: Agency Data______Other (such as census data)______
Of the total number of people served each year, what percent are:
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_____% White_____ % Income at or below Federal Poverty
_____% BlackGuidelines (maximum $24,250/year for a family of 4)
_____% Latino_____% Income up to 20% above Federal Poverty
_____% AsianGuidelines (maximum $29,100/year for afamily of 4)
_____% Native American _____% Children eligible for free/reduced
____% Children with disabilitiesschool lunch
____% Adults with disabilities
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Agency Certification
We certify that the information included in this agency update is true and complete to the best of our knowledge.
Agency DirectorStaff Contact at Agency - handling requests
Signature ______Signature ______
Name ______Name ______
(please print)(please print)
Date signed ______Date signed ______
Telephone ______Ext____Telephone ______Ext____
Community Events Invoice for July 2017-June 2018
For services through June 30, 2018
Agency Name: ______
Please return a copy of this invoice with your paymentagency update.
A copy of this invoice ensures that your account is credited accurately.
Your Agency Budget for FY17 (must be 3rd party verifiable): $______
Amount Due:$______
(Use sliding scale below to determine fee)
VSA arts of Georgia depends on donations to keep the fees low. Please consider an additional amount as a donation $______
▼
If your Agency Budget Is… Your 2017/2018 Fee Is…
Up to………………$250,000 $180.00
$250,001...... $500,000 $187.00
$500,001……… $1,000,000 $300.00
$1,000,001…… .$1,500,000 $323.00
$1,500,001...... $2,000,000 $478.00
$2,000,001……….$3,000,000 $595.00
$3,000,001...... $4,000,000 $714.00
$4,000,001...... and above $737.00
Make check payable to: GEORGIA COMMUNITY SUPPORT & SOLUTIONS
If paying by credit card:Circle: VISA MasterCard AMEX
Name on card Signature
(Please Print)
Card Number Expiration Date
Three or Four Digit Security Code:______(usually located on the back of a Visa or MasterCard and on the front of American Express)
Billing Address of the card (must have to process the card payment):
Address:______
City:______State:______Zip______
If you have any questions, please call the Community Events Coordinator at 404-221-1628
Mail or Email completed form with the Agency Invoice to:
Mail: VSA arts of Georgia, Georgia Community Support & Solutions,
1945 Cliff Valley Way, Suite 220,Atlanta, GA 30329
Email: