2015 SEFA CHARITY
APPLICATION FORM AND INSTRUCTIONS
Please read these instructions first and review the application on our website www.sefanys.org before
attempting to complete the Application Form. The deadline for submission is January 15, 2015. Once
you have all of the required information, complete the digital Application Form and submit it by clicking the
submit button at the end of the form. Application Forms may not be faxed or submitted in any other
format than that which appears once you click the submit button.(Note: If an email window does not
open with your application as an attachment, save your document to your hard drive, open an email attach
your form and documents and send them to [email protected].) Once you have submitted your
electronic Application Form you can save and print it. All required supporting documents can be attached to
the email the Application Form creates once the submit button is clicked or can be mailed along with a copy
of the first page of the Application Form and must be postmarked no later than January 15, 2015.
Absolutely NO hand deliveries will be accepted.
Statewide SEFA Council
17 Campus View Drive
Loudonville, NY 12211
All supporting documentation must be sent in one email or one package along with a copy of the first page
of the Application Form.

The Application Form is used for charities seeking to participate for the first time or for those
charities that have been removed from participation through failure of recertification.
o Failure of Recertification - Once admitted, charities are required to recertify annually.
Failure to recertify in any year will result in the charity’s removal and require a new
application to be submitted for the following year.

Please check the online listing of SEFA charities at www.sefanys.org for your charity. If your charity
is not listed then you will need to complete and submit the application form in order to be included
in the 2015 charity listing. This is required even if your charity has been admitted in the past.
o If your charity is listed then you do not need to complete the application form. You will need
to complete a charity recertification form. This form will be posted to the website by
January 15.

The use of the term “applicant” on the Application Form refers to the charity applying for
participation in the SEFA campaign.

You are required to answer all questions. If you fail to provide answers to required questions, your
application will be denied.

Once you have all of the required information complete in the digital Application Form, click on the
submit button at the end of the Application Form. Once you have successfully submitted your
Application Form you will receive an email confirming your submission was received. If you do not
receive an email receipt within 2 hours please contact [email protected].

Please note: Required documents not received by the deadline will result in the application being
considered incomplete; and subject to denial by the Council. Therefore it is very important that
you send required documents by the deadline.

Do not submit required documents in binders or folders of any kind.

Do not submit any documents or materials that are not requested.
Questions?
There will be four webinars offered to answer questions.
December 9, 2014 at 10:00 AM
December 10, 2014 at 1:30 PM
December 10, 2014 at 10:00 AM
If you have further questions contact the Statewide SEFA office at [email protected].
Notification
All applicants will receive notification of their approval or denial. There is no administrative appeal for
applicants that have been denied in recognition of the belief and conviction that the distribution of voluntary
contributions of state employees should be solely the decisions of such employees or their authorized
representation. However an appeal is possible in accordance with Article 78 of the Civil Practice Law and
Rules. The Commissioner of NYS Office of General Service is a necessary party to an appeal made in
accordance with Article 78.
To participate in SEFA a charity must make application to the Statewide SEFA Council. The application
period is December 1 through January 15 annually. The application is posted on the website
www.sefanys.org during that time.
To be eligible to participate in SEFA
You must meet the following qualifications to be accepted:
1. 501 (c) 3 IRS filing status and current with filing.
2. Be registered and current with the NYS Charities Bureau.
3. Have had at least two years of IRS Form 990s.
4. Produce an annual report. (This can be a simple statement relating expenses to programs
success).
5. Comply with all New York State and federal laws and regulations related to nondiscrimination as
well as equal employment opportunities with respect to its officers, staff, employees, volunteers
and all persons it seeks to serve.
6. Agree to abide by all SEFA policies and procedures for the annual solicitation campaign.
7. Capable of certifying that their organization is in compliance with all statutes, executive orders, and
regulations restricting and prohibiting U.S. persons from engaging in transactions and dealings with
countries, entities or individuals subject to economic sanctions administered by the U.S.
Department of the Treasury’s Office of Foreign Assets Control.
8. Be authorized to sign the SEFA application on behalf of your organization.
To apply to participate in SEFA:
1. You must meet all requirements as stated above and be able to provide supporting documentation.
2. You must fill out and sign an electronic form found on www.sefanys.org and submit it and all
supporting documentation on or before the deadline of January 15. It is highly recommended that
you do so well before the deadline.
3. The form and all required documentation must either accompany the electronic form in the email
that opens after clicking on the submit button on the form or in one package postmarked no later
than January 15.
4. The Statewide SEFA Council reviews all applications. Acceptance or denial communications are
then sent to all applicants whose form was received on or before the deadline.
How to fill out the SEFA Charity Application
1. Fill in your organization’s legal name.
2. If you have a DBA and wish to be listed under this DBA please check mark this box.
Note: A DBA is known as a “Doing Business As.” This can be the acronym of your organization or
another name it is known to the public by. To be listed under this name your organization must
have file an application to the IRS to be listed under this name.) If you check this box you must
attach a copy of the letter from the IRS approving your organization’s use of the DBA check the
which of the two boxes identifies how you wish to be listed.
3. Enter your EIN. (Note: This is your “Employer Identification Number,” this is the number the IRS
assigned to your organization when it applied to the IRS to become a nonprofit. You can find it on
your 990.)
4. Enter your mailing address.
5. Enter your phone number and fax number.
6. Enter the name and email of your CEO, CFO or Executive Director.
7. Enter the name and email for the person that manages your organizations finance information.
8. If your organization is tax exempt under IRS code 501 (c) 3, check this box.
9. Will you be attaching a copy of your 990 to this email or sending it via regular mail with all other
required documents? Check which ever box and answers this question.
Note: All required documents must all be in the email or all in the package mailed by regular mail.
If you filed a 990 EZ attached Pages 1 and 2.
10. If you are not required to file a 990 or 990EZ attach a copy of the letter from the IRS stating your
organization is not required to file annually.
Enter your fiscal year
11. Enter your New York State Charities Bureau registration number here.
Note: Educational organizations, libraries and some other organizations are not required to file with
the Charities Bureau. To be sure you are registered or are not required to file with the charities
bureau go to http://www.charitiesnys.com/RegistrySearch/search_charities.jsp or call 212-4168401.
12. Does your organization spend $62,000 or more statewide on program services? If so check this
box.
OR
13. Does your organization provide $1,000 or more on program services in a local area? If so check
this box. Note: If you chose local please tell us which campaign areas you are applying to.
14. Are you already participating in local campaign areas and are applying to others this year? If so
please tell us which campaign areas you are already participating in.
15. Please provide a copy of your most recent annual report or provide a brief description of your
organizations announced programs, goals and data demonstrating the extent of its achievements
including, where applicable, the extent of participation of its volunteers in the preceding year.
Check this box acknowledging attachment of report.
16. Does your organization provide health, welfare or recreational services? Check yes or no.
17. Write a brief description of what your organizations does.
Note: This is what a potential contributor is going to read when making the decision to contribute.
You have 25 words, make them count, don’t enter your organizations administrative fundraising
rate, name or EIN in this section.
18. Enter Management and General expense into the corresponding box.
19. Enter Fundraising expenses into the corresponding box.
20. Enter your organizations total Revenue.
Note: This form automatically calculates the total expenses and divides it by your total revenue
and populates your Administrative Fundraising Rate (AFR). This rate should be no more than 25%.
If your AFR is more than 25% you MUST attach an explanation describing why the AFR is more
than 25%, a plan and a time line for reducing the AFR below 25%.
21. Did your organization apply for an extension from the IRS? If so check this box and attach a copy
of the letter from the IRS approving this extension.
22. Does your organization comply with all state and federal laws and regulations related to
nondiscrimination as well as equal employment opportunities with regard to officers, staff,
employees and volunteers and all persons it seeks to serve? If you can certify to this check this
box.
23. Check this box to certify that your organization will abide by all SEFA policies and procedures for
the annual solicitation campaign.
Note: This means that you are aware that SEFA requirements are the responsibility of the charity
and that you are aware there is an annual recertification your organization is required to comply
with.
24. Check this box to certify that your organization has available for public inspection a copy of it 990.
25. Check this box to certify that your organization is in compliance with all statutes, Executive order,
and regulations restricting and prohibiting U.S. persons from engaging in transactions and dealings
with countries, entities or individuals subject to economic sanctions administered by the U.S.
Department of the Treasury’s Office of Foreign Assets Control. The organization named in this
application is aware that a list of countries subject to such sanctions, and overviews and guidelines
for each such sanction program can be found at http://www.treas.gov/ofac.
26. Type your name and your organizations name, type your name in the signature section and type
the date along with your title.
RESET FORM
2015 SEFA CHARITY APPLICATION
IDENTIFYINGINFORMATION
1.
Legal Name of Applicant Organization
Letter Approving DBA Attached
2.
DBA (name of applicant commonly used)
How do you wish to be identified in the SEFA listings?
Legal Name
DBA
Note: If the legal name of the organization differs from the name on the IRS determination letter, IRS form 990, or
audited financial statements, official documentation from the IRS or state government authorizing use of this name
must be mailed along with all other required documentation, as well as the EIN.
3.
Applicant’s Federal Taxpayer Identification Number (EIN)
(enter EIN as 12-1234567)
To find your EIN Taxpayer Identification Number go to:
http://www.irs.gov/taxstats/charitablestats/article/0,,id=97186,00.html , scroll down to the box for New York, click on the
alphabetical listing for your charity name. This will open an excel spreadsheet. Once the spreadsheet is open push the
control button on your keyboard at the same time you press the F4 key. Once the “find” box opens type in your charity
name. This should bring you to your EIN number.
4.
Mailing Address
Street address or P.O.
5.
City
Telephone Number
State
Fax Number
(enter ONLY numbers)
6.
(enter ONLY numbers)
Executive Director (or agency’s CEO or lead staff person)
Name
Title
Email
Contact person for this application – Optional (only if different from above)
Name
Title
Email
Name Applicant web address
1
Zip code
7.
Contact person Responsible for Accounting
Name
Title
Email
IRS STATUS
SEFA REGULATIONS REQUIRE TWO YEARS OF FILINGS TO BE ELIGIBLE TO PARTICIPATE IN THE CAMPAIGN.
8.
Is the applicant tax exempt under IRS code 501(c)(3)?
YES
NO (See #10)
Note: This is the letter your organization received when they originally applied to the IRS for their 501(c) 3 tax status.
If yes, attach a copy of agency’s IRS tax exempt letter.
Exempt Letter will be sent via email
Exempt Letter will be mailed.
9.
Will you be attaching a copy of your 990 to this email or sending it via regular mail with all other required documents?Attach a
signed copy of latest 990 which must include signature of Agency’s representative and paid preparer (if any).
990 or 990EZ and Pages 1-2 OF 990 will be sent via email
990 or 990EZ and Pages 1-2 OF 990 will be mailed
Note: Agencies that file a 990EZ must submit a copy a long with pages 1-2 of the 990.
Last date of your fiscal year:
December 3
10.
June 30
Other:
If you are exempt from filing please attach the letter from the IRS that states why you are exempt.
IRS letter will be sent via email
IRS letter will be mailed
CHARITIES BUREAU – NYS ATTORNEY GENERAL
11.
Provide Charities Registration ID #: 00-00-00
The ID should be 6 digits long.
APPLICATION TYPE
This application is for participation in:
12.
The statewide campaign – every local SEFA campaign in NYS. (Statewide applicants must
provide $62,000 or more in program services.)
2
OR
13.
A single local SEFA campaign. (Applicants to one or more local campaigns must show that they
provide a minimum of $1,000 in program services to that campaign area.)
AND
14.
Please check below the one, single local SEFA Campaign you are applying to participate in.
See attached list of counties that each SEFA campaign covers.
Allegany County
Delaware/Otsego Counties
Greater Rochester
Broome/Chenango/Tioga Counties
Dutchess County
Rockland County
Capital Region
Herkimer/Madison/Oneida
Counties
St. Lawrence County
Central New York
Jefferson/Lewis Counties
Steuben/Yates Counties
Chautauqua County
Long Island
Sullivan/Ulster Counties
Chemung County
New York City
Tompkins/Schuyler Counties
Clinton/Essex/Franklin/
Hamilton Counties
Niagara Frontier
Westchester/Putnam Counties
Cortland County
Orange County
Please Note: if the applicant is applying to participate in one or more local SEFA campaigns, you must submit one complete application
with attachments for each local campaign you want to be considered for (e.g.: if applying for participation in 3 local campaigns, you must
submit 3 applications with attachments and with the appropriate campaign area checked off on each). An applicant to participate in every
local campaign (statewide) may submit one application with attachments.
Please check off any local campaigns in which your organization has previously been approved to participate.
Use this area only if you have participated in SEFA previously.
Allegany County
Delaware/Otsego Counties
Greater Rochester
Broome/Chenango/Tioga Counties
Dutchess County
Rockland County
Capital Region
Herkimer/Madison/Oneida
Counties
St. Lawrence County
Central New York
Jefferson/Lewis Counties
Steuben/Yates Counties
Chautauqua County
Long Island
Sullivan/Ulster Counties
Chemung County
New York City
Tompkins/Schuyler Counties
Clinton/Essex/Franklin/
Hamilton Counties
Niagara Frontier
Westchester/Putnam Counties
Cortland County
Orange County
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15.
Please attach a copy of your latest Annual Report.
Annual Report will be sent via email
Annual Report will be mailed
SERVICES
16.
Does the applicant provide health, welfare or recreational services?
YES
17.
Please provide a 25 word description of your agency’s services (no attachments).
NO
Enter the description below. Please type accurately as what you write will be used in the
directory and brochures.
ADMINISTRATIVE AND FUNDRAISING EXPENSES CALCULATION
This percentage is computed from the IRS Form 990. The percentage is calculated by adding the amount
in Part IX (Statement of Functional Expenses), Line 25, Column C (Management and General Expenses) to the
amount in Line 25, Column D (Fundraising Expenses), and dividing the sum by Part VIII (Statement of Revenue),
Line 12, Column A (Total Revenue). No other methods may be used to calculate this percentage.
Fiscal Year Ended:
NOTE: If you need to change any value, please click the Reset
button then enter your values again and it will re-calculate.
18.
Management and General Expenses
19.
Fundraising Expenses
+
$
Total
=
$
Total Revenue
÷
$
Overhead Percentage
=
20.
$
0.00
0.0
%
RESET
NOTE: If the organization’s administrative and fundraising expenses exceed 25% of total revenue then a
justification or a formal plan and a timetable to reduce it to under 25% must be completed.
4
The overhead is over 25% and I have prepared the justification or formal plan.
The overhead is under 25%.
I certify that the administrative and fundraising rate for the organization named in this application
is
21.
0.0
%.
Did your organization apply for an extension from the IRS?
YES
NO
IRS approval of extension letter will be sent via email
IRS approval of extension letter will be mailed
REPRESENTATIONS AND CERTIFICATION
Place a check (X) in the Yes or No box after each statement.
22.
Applicant complies with all requirements of state and federal laws
and regulations related to nondiscrimination as well as equal employment
opportunities with respect to its officers, staff, employees, volunteers and
all persons it seeks to serve.
YES
NO
(Applicants that are otherwise eligible, will not be denied because it is organized
by, on behalf of, or to serve persons of a particular race, color, religion, sex,
sexual orientation, national origin, age, or with a particular disease or handicap.)
23.
The Applicant agrees to abide by all SEFA policies and procedures for the
annual solicitation campaign.
YES
NO
24.
The Applicant agrees to make available IRS Form 990 to any requestor
pursuant to section 6104(d)(4) of the Internal Revenue Code and applicable
Internal Revenue Service regulations.
YES
NO
25.
I certify that the organization named in this application is in compliance with all
YES
statutes, executive order, and regulations restricting and prohibiting U.S.
persons from engaging in transactions and dealings with countries, entities or
individuals subject to economic sanctions administered by the U.S. Department
of the Treasury’s Office of Foreign Assets Control. The organization named in this
application is aware that a list of countries subject to such sanctions, and overviews
and guidelines for each such sanction program can be found at http://www.treas.gov/ofac
Should any change in circumstances pertaining to this certification occur at any time, the
organization will notify the SEFA Council immediately.
NO
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26.
CERTIFYING OFFICIAL
, am authorized by
I,
to certify
(applicant)
and affirm that all statements contained in and attached to this application are complete and accurate.
Name
Title
Organization Name
Date
6
Documents Required For This Application
Items checked below will be emailed
IRS Tax Exempt Letter attached in email
990 or 990EZ AND Pages 1 – 2 of 990 attached in email
IRS Letter explain why not required to have 501(c)(3) attached in email
IRS approval of extension letter will be sent via email
Annual Report will be sent via email
Items checked below will be mailed
IRS Tax Exempt Letter to be mailed
990 or 990EZ AND Pages 1 – 2 of 990 to be mailed
IRS Letter explain why not required to have 501(c)(3) to be
mailed IRS approval of extension letter will be mailed
Annual Report will be mailed
SUBMIT
NOTE: The SAVE and PRINT button will appear once your application has
been validated after clicking the SUBMIT button.
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