501c3 Assessment - The 50 States Start-Up Challenge

501c3 Tax Exemption Assessment

Please set aside 2 to 3 hours complete the form below. Once completed, if you would like to have 50 State Start-Up Challenge review how we can help your company with business development coaching or provide business formation services, please let us know at the end of the 501c3 Tax Exemption Assessment. BY SIGNING AND SUBMITTING THIS ONLINE FORM, YOU ARE AGREEING THAT YOU HAVE THE AUTHORITY TO COMMUNICATE AND EXECUTE ALL BUSINESS DEALINGS WITH 50 State Start-Up Challenge.

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Company Basics

Full Name of Organization*

(exactly as it appears in your organizing document)

Official Company Representative Full Name*

Person to Contact if More Information is Needed (officer, director, trustee, or authorized representative)

Company Representative Phone #*

Mailing Address*

include City, State, Zip, and Suite

Employer Identification Number*

Please provide your Employee Identification Number or Tax Identification Number

Company Fax Number*

Organization's Website (if available):*

Contact / Organization Email address*

Compensation and Other Financial Arrangements

Do you or will you compensate officers, directors, or trustees, or do or will you have highest compensated employees, or highest compensated independent contractors?

Do or will the individuals that approve compensation arrangements follow a conflict of interest policy?

Do or will you approve compensation arrangements in advance of paying compensation?

Do or will you document in writing the date and terms of approved compensation arrangements?

Do or will you record in writing the decision made by each individual who decided or voted on compensation arrangements?

Do or will you approve compensation arrangements based on information about compensation paid by similarly situated taxable or tax-exempt organizations for similar services, current compensation surveys compiled by independent firms, or actual written offers from similarly situated organizations?

Do or will you record in writing both the information on which you relied to base your decision and its source?

Do or will you have any other practices you use to set reasonable compensation? If "Yes," describe these practices.

Have you adopted a conflict of interest policy consistent with the sample conflict of interest policy in Appendix A to the instructions? If you are a hospital, answer "Yes" if your conflict of interest policy includes provisions consistent with the additional healthcare related provisions in the sample document. If "No," describe the procedures you will follow to ensure that persons who have a conflict of interest will not have influence over setting their own compensation or regarding business deals with themselves.

Do you or will you compensate any of your officers, directors, trustees, highest compensated employees, and highest compensated independent contractors through non-fixed payments, such as discretionary bonuses or revenue-based payments? If "Yes," describe all non-fixed compensation arrangements, including how the amounts are determined, who is eligible for such arrangements, whether you place a limitation on total compensation, and how you determine or will determine that you pay no more than reasonable compensation for services.

Do you or will you have any leases, contracts, loans, or other agreements with: (i) your officers, directors, or trustees; (ii) any family of any of your officers, directors, or trustees; (iii) any organizations in which any of your officers, directors, or trustees are also officers, directors, or trustees, or in which any individual officer, director, or trustee owns more than a 35% interest; (iv) your highest compensated employees; or (v) your highest compensated independent contractors? If "Yes," describe any written or oral arrangements that you made or intend to make, with whom you have or will have such arrangements, how the terms are or will be negotiated at arm's length, and how you determine you pay no more than fair market value or you are paid at least fair market value.

Answer below

Do you or will you contract with another organization to develop, build, market, or finance your facilities? If "Yes," describe each facility, the role of the other organization, and any business or family relationship between the organization and your officers, directors, or trustees. Explain how that entity is selected, how the terms of any contract(s) are negotiated at arm's length, and how you determine you will pay no more than fair market value for services.

Does or will someone other than your own employees or volunteers manage your activities or facilities? If "Yes," describe the activities or facilities that will be managed by others, the names of the persons or organizations that manage or will manage your activities or facilities, and any business or family relationship between the organization and your officers, directors, or trustees. Explain how these managers were or will be selected, how the terms of any contracts or other agreements were or will be negotiated, and how you determine you will pay no more than fair market value for services

Do you or will you make grants, loans, or other distributions to foreign organizations? If "Yes," name each foreign organization (if not already provided), the country and region within each country in which each foreign organization operates, any relationship you have with each foreign organization, and whether the foreign organization accepts contributions earmarked for a specific country or organization (if so, specify which countries or organizations).

Do you or will you purchase or sell any goods, services, or assets from or to: (i) any of your officers, directors, or trustees; (ii) any family of any of your officers, directors, or trustees; (iii) any organizations in which any of your officers, directors, or trustees are also officers, directors, or trustees, or in which any individual officer, director, or trustee owns more than a 35% interest; (iv) your highest compensated employees; or (v) your highest compensated independent contractors? If "Yes," describe any such transactions that you made or intend to make, with whom you make or will make such transactions, how the terms are or will be negotiated at arm's length, and how you determine you pay no more than fair market value or you are paid at least fair market value.

Answer below

Do you participate in any joint ventures, including partnerships or limited liability companies treated as partnerships, in which you share profits and losses with partners? If "Yes," state your ownership percentage in each joint venture, list your investment in each joint venture, describe the tax status of other participants in each joint venture (including whether they are section 501(c)(3) organizations), describe the activities of each joint venture, describe how you exercise control over the activities of each joint venture, and describe how each joint venture furthers your exempt purposes.

Do your contributors know that you have ultimate authority to use contributions made to you at your discretion for purposes consistent with your exempt purposes? If "Yes," describe how you relay this information to contributors.

Do you share board members or other key personnel with the recipient organization(s)? If "Yes," identify the relationships

Select the option that best describes you to determine the years of revenues and expenses you need to provide.

You completed less than one tax year.

You completed at least one tax year but fewer than five.

You completed five or more tax years.

Explain what your goal is at the end of this evaluation?*

How would you like to be contacted?

Home / office

Mobile / cell phone

Mobile Tel

Home Tel

Email address*

This field should be left blank

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