The undersigned, to assist grant-making foundations in the United States of America determine whether [name of grantee organization] (the grantee organization) is the equivalent of a public charity described in section 509(a)(1), (2) or (3) of the United States Internal Revenue Code or a private operating foundation described in section 4942(j)(3) of the Code, makes the following statement:
(1) I am the [title of principal officer] of the grantee organization.
(2) The grantee organization was created by [identify statute, charter, or other document] in [year], and is operated exclusively for [check applicable box or boxes]:
(3) The activities of the grantee organization have included [describe past activities and operations], and will include [describe future activities and operations].
(4) Copies of the charter, bylaws, and other documents pursuant to which the grantee organization is governed are attached.
(5) The laws and customs applicable to the grantee organization do not permit any of its income or assets to be distributed to, or applied for the benefit of, a private person or non-charitable organization other than pursuant to the conduct of the grantee organization's charitable activities, or as payment of reasonable compensation for services rendered or as payment representing the fair market value of property which the grantee organization has purchased.
(6) The grantee organization has no shareholders or members who have a proprietary interest in the income or assets of the organization.
(7) In the event that the grantee organization were to be liquidated or dissolved, under the laws and customs applicable, or under the governing instruments, all its assets would be distributed to another not-for-profit organization for charitable, religious, scientific, literary, or educational purposes, or to a government instrumentality. A copy of the relevant statutory law or provisions in the governing instruments controlling the distribution of the organization's assets on liquidation is attached.
(8) The laws and customs applicable to the grantee organization do not permit the organization, other than as an insubstantial part of its activities,
(B) to attempt to influence legislation, by propaganda or otherwise.
(9) The laws and customs applicable to the grantee organization do not permit the organization directly or indirectly to participate or intervene in any political campaign on behalf of, or in opposition to, any candidate for public office.
(10) The grantee organization is not controlled by or operated in connection with any organization other than as follows [describe]:
(11) (The following is required only if the grantee organization's status under section 501(c)(3) and 4947(a)(1), 509(a)(1), (2), or (3) or section 4942(j)(3) of the Code depends on its financial support.) A schedule of support for the four most recently completed taxable years is attached showing (for each year and in total)
(B) Membership fees received;
(C) Gross receipts from admissions, merchandise sold or services performed, or furnishing of facilities in any activity that is not a business unrelated to the organization's exempt purposes;
(D) Gross income from interest, dividends, rents, and royalties;
(E) Net income from business activities that are unrelated to the organization's exempt purposes;
(F) The value of services or facilities furnished by a governmental unit without charge;
(G) The total of lines (A) through (F);
(H) Line (G) minus line (C);
(I) Two percent of line (H);
(J) A schedule of contributions for each donor whose support for the four-year period was greater than the amount on line (I) (a major donor), and showing the amount by which each major donor's total contributions exceeded the amount on line (I) (excess contributions);
(K) The sum of all major donor's excess contributions;
(L) The four-year total for line (H) minus the four-year totals of lines (D), (E), and (K) (the amount of public support);
(M) Line (L) divided by the four-year total for line (H) (the percentage of the organization's support that is public support).
(12) (The following is required only if the grantee is not a public charity described in section 509(a)(1), (2), or (3) of the Code but claims to be an operating foundation described in section 4942(j)(3) of the Code.) A schedule showing that the organization satisfies (i) the income test of section 43.4942(b)-1(a) of the regulations and (ii) one of the alternative tests described in section 53.4942(b)-2.
(13) (The following is required only if the grantee is a school described in section 170 of the Code.) The grantee organization is an organization described in section 170(b)(1)-(A)(ii) of the Code that has adopted and operates pursuant to a racially nondiscriminatory policy as to students, as set forth in Rev. Rul. 71-447, 1971-2 C.B. 230, and Rev. Rul. 75-231, 1975-1 C.B. 158, and as implemented in Rev. Proc. 75-50, 1975-2 C.B. 587.