United Way of Brevard
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Your organization may have received designations from the United Way of Brevard Community Campaign. In order to receive these funds you must complete the Patriot Act Compliance Form. This is an annual federal requirement. Failure to complete this form or qualify as a 501(c)3 organization in good standing with the IRS will result in the release of your funds back to United Way of Brevard for redistribution.

Your organization has received designations from the 2015 United Way of Brevard Community Campaign. This form must be completed to receive designation payments.
  1.)Organization Information
 a.) Enter your organization's EIN. *
 b.) Choose one answer from the drop down box. Does your organization offer primarily: *
 c.) Name of person completing this survey: *
 d.) Email of person completing this survey *
 e.) Full Legal Name of Organization *
 2.) Payment Information
 Electronic Fund Transfer (EFT) payments are made quarterly. If your organization does not enroll in EFT you will only receive one payment (paper check) in April of 2017 when the 2015 campaign payout cycle is complete. If you are not sure if your organization is currently enrolled or wish to enroll in the EFT payment program contact Debra Stull at United Way of Brevard at dstull@uwbrevard.org or by calling 321.631.2743. Select donor directed payments do not apply.
 I understand that if my organization chooses to not enroll in the EFT program with United Way of Brevard payments will not be paid quarterly to my organization but will be paid via one paper check in April 2017. YesNo
 a.) Payment Address: Street Address or P.O. Box
 b.) Suite/Mail Drop/Unit Number if applicable
 c.) City
 d.) State
 e.) Zip Code
 3.) Patriot Act Certification
"I certify that my organization has registered with the IRS as a 501(c)(3) organization, in good standing and eligible to receive tax-exempt donations." YesNo
" I hereby certify on behalf of my organization that all United Way of Brevard funds and donations will be used in compliance with all applicable anti-terrorist financing and asset control laws, statutes and executive orders." YesNo

Items marked with an asterisk(*) are required. Please review your responses and make sure you have answered every question with an asterisk (*).

Thank You

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