Fiscal Agent Certification Form

GRANT APPLICANT:      

Executive Director’s Name:       Phone Number:      Executive Director’s Email Address:       Agency’s Complete Mailing Address:      

☐I will be meeting with our fiscal agent to go over budget and billing procedures.☐I agree that the agency listed below will be our fiscal agent if the award is received for the life of the grant.☐Should the our agency fail to fulfill the terms of the grant, our agency agrees to notify the fiscal agent to return the balance of all unspent grant funds to the Washtenaw Coordinated Funders within 30 days of grant termination by the Washtenaw Coordinated Funders.☐Should either our agency or our fiscal agent decide to terminate this relationship, we agree to notify the Washtenaw Coordinated Funders within 14 days of reaching this decision.

Executive Director’s Signature: Date:      

FISCAL AGENT:      Agencies assuming fiscal sponsorship of a Washtenaw Coordinated Funders grantee must meet all of the following criteria: Must be a 501(c)(3) nonprofit organization. Incorporated under the laws of the State of Michigan. Currently registered with the State of Michigan under the Charitable Solicitations Act. Fiscally and administratively sound. An audit or a review of financial statements will be submitted for review. Compliant with the Federal Directive on non-discrimination Standard of Voluntary Health and Welfare Services (see

below).

Executive Director’s Name:       Phone Number:      Executive Director’s Email Address:       Agency’s Complete Mailing Address:      

Fiscal agents must provide the following to grant applicants prior to Request for Information (RFI) submission: Proof of 501c3 status by the Internal Revenue Service Evidence of financial controls (for the most recently concluded fiscal year): audit or a review of financial statements Affirmed compliance with the Federal Directive on non-discrimination Standard of Voluntary Health and Welfare

Services

Federal Directive on non-discrimination Standard of Voluntary Health and Welfare ServicesDoes your organization affirm that it is in compliance with the following Federal Directive on non-discrimination Standard of Voluntary Health and Welfare Services?

No person is excluded from service because of race, ethnicity, gender, age, physical disabilities, sexual orientation or gender identity.

There is no segregation of those served on the basis of race, ethnicity, gender, age, physical disabilities, sexual orientation or gender identity.

There is no discrimination with regard to hiring, assignment, promotion or other conditions of staff employment on basis of race, ethnicity, gender, age, physical disabilities, sexual orientation or gender identity.

Governing bodies are open to representation from all segments of the public, regardless of race, ethnicity, age, gender, physical disabilities, sexual orientation or gender identity.

☐I certify that our agency meets all of the above criteria.☐I have provided copies of the above documents to the grantee agency for submission to the Washtenaw Coordinated Funders. ☐We agree to serve as a fiscal agent for the Grant recipient listed above for the award received the life of the grant.☐Fee (if any) to be charged: $     ☐Should the grantee agency fail to fulfill the terms of the grant, our agency agrees to return the balance of all unspent grant funds to the Washtenaw Coordinated Funders within 30 days of grant termination by the Washtenaw Coordinated Funders.☐Should either our agency or the grantee decide to terminate this relationship, we agree to notify the Washtenaw Coordinated Funders within 14 days of reaching this decision.

Executive Director’s Signature: Print Name: Date:      

Board Chair’s Signature: Print Name: Date:      

For questions regarding the development of your fiscal agency agreement:

Washtenaw Coordinated Funders Point of ContactBridget Healy, Director of Community ImpactUnited Way of Washtenaw County734-677-7209bhealy@uwwashtenaw.orgwww.coordinatedfunders.org

2