Fiscal Sponsorship Application

Name of organization:

Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

State where organization is or will be incorporated: *

Date of incorporation:

Month Day Year

Date organization applied for its own 501(c)(3) if it already has:

Month Day Year

Tell us where you are in establishing your nonprofit status:

We are a startup We started up more than a year ago but have not accepted donations or are just getting our nonprofit status in order We are converting from a for-profit corporation to a 501(c)3 We are spinning off from another nonprofit We are seeking a new fiscal sponsor

If you are spinning off from another nonprofit, please name that organization:

If are seeking a new fiscal sponsor, please state your current sponsor and reason for changing:

Target date to be operating independently, if you have one:

Month Day Year

CEO or employee who is responsible for organization finances and development:

Name

First Name Last Name

Title

E-mail

Phone Number

Area Code Phone Number

Bookkeeping contact - person who will handle sponsorship and donation matters and be primary operational contact on a day to day basis:

Name

First Name Last Name

Title

E-mail

Phone Number

Area Code Phone Number

What is the mission of the project or program for which you are seeking sponsorship?

What funding do you have at least verbally committed to your nonprofit for the current year?

Please attach:

Your current or first-year budget with anticipated revenue, listing all sources over $25,000

Your business plan for the current or coming year *

If not covered in the business plan, your project plan and goals for the current or coming year

Revenue/operational and editorial/news goals

Short bios of the top officer of your nonprofit and your board chair

A list of all board members

Does your organization have any debts or legal action pending against it?

Yes No

If yes, please tell us about it:

Are you currently an INN member?

Yes No

If no, have you submitted an INN membership application and attest your organization will operate within the transparency, editorial independence and other guidelines of INN membership?

Yes No

Here's how to apply for membership.

Are you producing and publishing news at the current time?

Yes No

If yes, please provide the URL where we can see your publication or if you publish through third parties, see your editorial independence and other policies:

If not, when is your target date to begin producing and publishing?

Signature

Title

Date

Month Day Year