SUBMIT ANNUALLY                                D  O  C  U  M   E  N  T   A  T  I  O  N
Please Note:  If you are a local chapter of a larger organization, when submitting financial information, submit local amounts only.  Do Not submit a consolidated
Financial Statement and/or a consolidated form 990
       1.    A letter of request.  
       2.    A current list of the Board of Directors.    Year:_______
       3.    A copy of the current year Organization budget.    Year: ______ (If available, also budget for specific
               program request)
       4.    A copy of the prior year Balance Sheet and Profit/Loss Statement.    Year: __________ (No Consolidated forms)
       5.    A complete copy of your organization's most current Form 990.    Year: ____________ (No Consolidated forms)
       6.    List out prior year grants received, from whom and for how much. Also include a "grand-total" amount for revenue
               received through 1) private donations and 2) State/Federal/Local government.    Year:____________
       7.    List any political activities within the last 12 months:                                 No Political Activities  
       8.    A list of individual people served (including how many not duplicated) within the last 12 months, taking into consideration Federal law and policy
              of confidentiality, if  applicable, please include a list of organizations and/or institutions served. Demographic studies
              are also accepted.
                               Attached              Confidential                Demographic study                 Not Applicable  
       9.    If applicable, name, address, & phone number of national headquarters.  Are you required to give a percentage of
               your intake (grant) to the national headquarters?  No      Yes    If yes, how much?________    Not Applicable  
       10.  The Internal Revenue Service determination letter that classifies your organization as one that is exempt from
               taxation under IRS Code Section 501(c)(3). This same letter should also state that your organization is not a private
               foundation.  
       11.  A copy of the letter from the California Franchise Tax Board stating that the organization is exempt from the state
               franchise and income tax under California Revenue and Taxation Code Section 23701d.  

I,______________________________, an officer of the above name organization do hereby state that our exempt statues under

Section 501(c)(3), and our non-private foundation status, currently remain in effect under the Federal I.D. #:______________

Signature:____________________________________________Title: ________________________ Date: ________________

                                I do hereby certify that the information reported on this application form is complete and accurate.

Signature:____________________________________________Title: ________________________ Date: ________________