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Resource Impact Intake Form

Thank you for your interest in the services and support of Resource Impact. Please answer the below questions to the best of your ability. Simply enter N/A for questions that do not apply to your entity.

Entity Name

Contact First Name

Contact Last Name

Contact Email

Contact Phone

Address

EIN

IRS Classification

Place of Incorporation

When was the entity formed?

Registered agent (current or previously used)

Does intangible property exist?

Yes

If there is intangible property, please describe

Has the entity previously used a fiscal sponsor?

Yes

Who serves as the entity's leadership? Please include link to bio(s).

Please describe the entity's current staffing structure.

What is the entity's mission?

What are the core activities?

Is the entity intending to function as a time-limited campaign, or to eventually become an ongoing, independent organization?

What political or lobbying activities will the organization engage in?

Approximately what percentage of the organization's activities will be political or lobbying in nature?

If there are lobbying activities, please describe current compliance protocols.

Are there existing corporate bylaws?

Yes

Preferred Resource Impact role, if known.

Fiscal Sponsor

Fiscal Agent

Requested services and supports: please select all that apply:

Financial Compliance (i.e., 990)

State registration

State charitable registration

Contract management/responsibility

Member billing

Organizational coaching

Other

Please list all active contracts, indicating the vendor/consultant name, contract duration, and contract value.

Last period for which an IRS form 990 was filed, if any.

List current active grants, indicating which are restricted for 501(c)(3) charitable activities only.

What other assets does the entity currently have?

List grants actively applying for or pending, indicating which are restricted for 501(c)(3) charitable activities only.

Are there particular activities that are likely to require a specific Insurance need or present a specific risk exposure?

Yes

Please include (or email seperately) most recent profit and loss statement, if available.

Preferred effective date of fiscal sponsorship/agency:

525 9th St NW, 7th Floor
Washington, DC 20004

info@resourceimpactdc.org

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