Non Profit Organization Tax Intake Form

Organization Name:

Full Legal Name:
DBA (if applicable):

Contact Information:

Taxpayer's Social Security

Financial Information

Non-Profit Status

501(c)(3) Status:
EIN (Employer Identification Number):
Date of Incorporation:
State of Incorporation:

Fiscal Year

Start Date
End Date

Revenue

Sources of Revenue (e.g., donations, grants, service fees):
Source 1:
Source 2:
Source 3:

Expenses

Total Expenses:
Major Expense Categories (e.g., salaries, rent, program costs):
Category 1:
Category 2:
Category 3:

Program and Activity Information

Programs and Services

List of Major Programs/Services Provided:
Program/Service 1:
Program/Service 2:
Program/Service 3:

Volunteer Information

Number of Volunteers:
Total Volunteer Hours:

Compliance and Governance

Board of Directors

Names and Titles of Board Members:
Member 1:
Member 2:
Member 3:

Compliance:

Is the organization in compliance with all federal, state, and local regulations?
Has the organization filed all required tax forms for the previous year?
Has the organization undergone any audits or financial reviews in the past year?

Additional Information

Attachments

Attach copies of the following documents:
Most recent IRS Form 990
Financial Statements (Income Statement, Balance Sheet)
Bank Statements for the fiscal year
Receipts for major expenses
Documentation for donations and grants

Additional Notes

Any other relevant information or notes for ARC Tax preparer:

Please upload your tax exempt documentation

Authorized Signature

Name
Title

Signature and Date

Signature

Date