Nonprofit Governance Assessment Intake Application

This Intake Application is preliminary to the Nonprofit Governance Assessment and will help you determine if your organization is ready to proceed. Once completed, our legal team will contact you to discuss the engagement and confirm your interest. If you are ready to move forward, our legal team will review the core governance documents in conjunction with our interviews of your designated representatives. Please identify two representatives (ideally the Board Chair or Governance Committee Chair and Executive Director/CEO) who will be available to answer an Online Questionnaire for comprehensive data collection about your governance documents and practices, and who will participate in a conference call with a member of our legal staff within two weeks of receipt of the organization’s documents.

Question Title

* 1. Organization Name

Question Title

* 2. EIN (Employer Identification Number)

Question Title

* 3. Web Address

Question Title

* 4. Primary Contact for the Governance Assessment

Name

Title

Email Address

Phone Number

Question Title

* 5. Secondary Contact for the Governance Assessment

Name

Title

Email Address

Phone Number

Question Title

* 6. Number of Full-Time Staff

Question Title

* 7. Accounting Year End (e.g., June, December)

Question Title

* 8. Has the organization ever lost tax-exempt status due to Automatic Revocation or any other reason? (please describe)

Question Title

* 9. Date of Formation

Question Title

* 10. Please upload a copy of your Articles of Incorporation and any Articles of Amendment

Question Title

* 11. Date of IRS Determination Letter

Question Title

* 12. Please upload a copy of your IRS Determination Letter

Question Title

* 13. Does the organization have a mission statement approved by the Board? If so, please provide your mission statement here.

Question Title

* 14. Does your organization have written bylaws?

Yes

Question Title

* 15. If yes, please upload a copy of your current bylaws

Question Title

* 16. How many board members are currently serving?

Question Title

* 17. Does your organization have a Conflict of Interest Policy?

Yes

Question Title

* 18. If yes, please upload a copy of your current Conflict of Interest Policy

Question Title

* 19. Please provide your most recent 990 (or 990EZ or 990N)

Question Title

* 20. By submitting this Intake Application, I acknowledge that my organization’s committee or designee will be required to provide information and documentation as requested for Maryland Nonprofits to conduct the Nonprofit Governance Assessment. (type your full name to affirm)