California Victim Compensation and Government Claims Board

Applications

If the date for filing the 2008 Application has passed and your organization wishes to participate in the campaign next year, please submit the following information:

Please type or print legibly:

  1. Name of Agency as recognized by the Internal Revenue Service as tax exempt under Title 26, U.S. Code, § 501(c)(3). (If the names do not match the name referenced on the I.R.S exempt letter, please include a letter from the I.R.S. or other state issued documentation authorizing any legal name change). Acceptable documentation may include:
    a) Amendment to the Articles of Incorporation
    b) A doing business as (DBA) statement
    c) A fictitious business name statement
    d) I.R.S. acknowledgment of amendment
  2. Address
  3. ORIGINAL signature*
  4. Copy of the organization's I.R.S. 501(c)(3) designation, include a letter from the IRS or other state issued documentation authorizing any legal name change. Any questions regarding this requirement should be directed to Marilyn Louie at (916) 491-3726 or marilyn.louie@vcgcb.ca.gov.
  5. Expenses, indicate the estimated percentage of annual contributions spent for fundraising and administrative costs.
  6. Names of the counties in which you will solicit funds.
  7. For PCFDs: please indicate the counties in which you operate (please specify the geographic boundaries of your area, if it does not encompass an entire county).
  8. Include a 25-word, or less, description of the health, welfare or human care services that the organization provides. (Note: this description may appear in the brochure distributed to all State employees.)**

*Under penalty of perjury your signature signifies that your agency complies with the conditions set forth within the application.

**The 25-word statement should not repeat the name of the organization nor should it exceed 25 words. A Website address may be included for additional information regarding the organization and will not be counted as part of the 25-word statement. E-mail addresses will not be accepted. VCGCB staff will edit statements submitted with more than 25 words.