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BBB-WMI LCR Questionnaire for Electronic Filing

BACKGROUND & PROGRAMS

Organization Name:
Address:
City:
State:
Zip:
Mailing Address: (if different than above)
Phone:	()-
Fax:	()-
Website:
Email 1:
Email 2:
Date Established:

Stated purpose of organization:

Summary of principal activities:

Have there been any significant changes in your organization's purpose and/or program activities
in the past year? (i.e. amending of the official mission statement, adding or eliminating a program, etc)
If so, please explain:

Number of Employees:

Number of Volunteers:

GOVERNANCE & OVERSITE

Please indicate "yes" or "no" next to each of the following items.
Does your Board of Directors and/or a committee of the Board:
(*you will be required to submit a copy of all information with an asterisk*)

Yes	No
		Formally review the performance of the CEO at least once every two years?
		Formally approve an annual budget? * std. #14
		Ensure that arrangements with outside fund raising firms are made in writing?
		Formally approve a conflict of interest policy? * std. #5
		Receive, on an annual basis, IRS form 990 *
		Receive, on an annual basis, an Audited Financial Statement * std. #8,9,10, 11,12,13
		Receive, on an annual basis, an Auditor's Management Letter

On the following charts, please list the dates of all Board and Executive Committee meetings held during the past year and indicate the number of voting members who attended the meeting and the total voting membership at the time of the meeting. If any of the members participated either by telephone or by proxy (as opposed to in-person), please indicate the number of either telephone or proxy attendance for each meeting. Std. # 3

Meeting information for Fiscal Year Ending: Month: Year:

Board of Directors Meeting Attendance

Date of Meeting	Number of Members Attending	Number of Members by Phone	Number of Members by Proxy	Total # of Voting Members

Executive Committee Meeting Attendance

Date of Meeting	Number of Members Attending	Number of Members by Phone	Number of Members by Proxy	Total # of Voting Members

Are any voting members of the Board are directly or indirectly compensated? If yes, please provide name(s), title and total compensation during the past fiscal year. Std. # 4

Voting Board Member Name	Title	Compensation during past fiscal year.

Are any members of the Board of Directors relatives of fellow Board or staff members of the organization? If yes, please complete this schedule identifying the names, titles and relationships.

Member Name	Title	Relationship

Within the past year, has your organization purchased goods or services from any member of the Board, Executive Committee and/or professional staff, or from any firm or organization with which they (or a direct family member) are affiliated? If YES, in the space provided below, please identify the following: std. # 5

Names and titles of individuals
Goods or services purchased
Amounts paid for good or services
Steps taken to ensure arm's length transactions

Within the past year, has your organization made any grants, contributions or loans to any member of the Board or Executive Committee, or to any institution or firm with which they are affiliated? If YES, in the space provided below, please identify the following:

Names and titles of individuals
Details of the arrangements
Amount of award or loan
Steps taken to ensure arm's length transactions

EFFECTIVENESS

Does your Board have a policy of assessing, no less than every two years, your organization's performance and effectiveness, and of determining future actions required to achieve its mission? If YES, in the space provided below, please paste a copy of your Board policy, or mail to the bureau under separate cover: std. # 6

Yes	No
		Does your organization submit to its governing body for its approval, a written report that outlines the results of the aforementioned performance and effectiveness assessment and recommendations for future actions. Std # 7

FUND RAISING AND INFORMATIONAL MATERIALS

What is the scope of your fund raising activities?
	Local
	Regional
	National
	International

Type of tax exemption:
	501(c)(3)
	Other (please specify)

Fund Raising Requests (Please check all fund raising methods used in the past year, and mail to the bureau under separate cover, copies of all versions of appeals used.) std. #15
	Direct Mail Appeals		Membership Appeals
	Telephone Appeals		Invitations to Fund Raisers
	Scripts for TV/Radio Appeals		Grant Proposals
	Print Advertisements (Newspapers, Magazines)	Other, please specify

Please indicate "yes" or "no" next to each of the following items.
(*you will be required to mail to the bureau, under separate cover, a copy of all information with an asterisk*)

Yes	No
		Did your organization employ outside fund raising firms or consultants in the past year? * If YES, please send a copy of each such agreement
		Does your organization engage in any cause-related marketing efforts? * If YES, please send copies of promotional materials related to these arrangements
		Does your organization share the names and addresses of your donors with outside parties? * std. #18
		If YES to the preceding question, do you annually provide a means (for both new and continuing donors) to inform you if they do not want their name & address shared outside your organization? * If YES, please send a sample of the appeal including this option

FORM SUBMISSION

Name of person who completed and submitted this form:
Daytime Phone:	()-
Your Email:

CHECKLIST ITEMS

CHECKLIST: ITEMS YOU WILL BE REQUIRED TO SEND TO THE BBB of WESTERN MICHIGAN (UNDER SEPARATE COVER) IF NOT INCLUDED IN THIS ONLINE FORM
IRS DETERMINATION LETTER - first year only ARTICLES OF INCORPORATION - first year only BY-LAWS - first year only INFORMATION / MARKETING MATERIALS AGREEMENTS with AFFILIATES CONFLICT of INTEREST POLICY (Board approved) LIST of BOARD of DIRECTORS & OFFICERS STATE LICENSE - copy ANNUAL REPORT UPDATE	FUNDRAISING CONTRACTS / AGREEMENTS SOLICITATION MATERIALS CAUSE RELATED MARKETING MATERIALS & DETAILS TELEPHONE SCRIPT - if used IRS 990 for latest year ANNUAL FINANCIAL STATEMENT CURRENT YEAR BUDGET DATE, PLACE, & # of ATTENDEES for BOARD MEETINGS IN PAST YEAR

*SEND TO BBB of WESTERN MICHIGAN ATTN: LCR MANAGER*
MAIL:	BBB-WMI LCR PROGRAM 40 PEARL NW, Suite #354 GRAND RAPIDS, MI 49503	FAX #:	616-774-2014	E-MAIL:	bbbops@iserv.net

A BBB-WMI LCR report for your organization will be developed in the near future; a copy of which will be sent to you.
The BBB NAME & LOGO MAY NOT USED FOR "ANY" PURPOSE UNLESS SPECIFICALLY NOTED IN WRITING BY THE BBB-WMI.
BBB REPORTS are copyrighted and may not be reproduced for promotional purposes or used in any fashion.

© 2012 Council of Better Business Bureaus