SOUTH CAROLINA SECRETARY OF STATE PUBLIC CHARITIES DIVISION APPLICATION FOR PAYROLL DEDUCTION Filing Instructions All payroll deduction applications must be submitted to the Secretary of State's Office by September 1st. A list of all charitable organizations requesting funding from your agency must be submitted with this application. Please submit this form to the South Carolina Secretary of State's Office, Division of Public Charities, 1205 Pendleton Street, Suite 525, Columbia, SC 29201. Please contact our office with any questions regarding this form at 803-734-1790 or email charities@sos.sc.gov. Please type or print clearly. 1. Name of Charitable Organization: _______________________________________ Charity Public ID: _____________ A list of all charitable organizations requesting funding from your agency must be submitted with this application. 2. Please provide a contact person for your organization: __________________________________________________________________________________________ Name Address, City, State, Zip Code Email __________________________________________________________________________________________ __________________________________________________________________________________________ Daytime Phone ___________________________________________________________________________________ I hereby certify that the above is a nonprofit, eleemosynary corporation, association or organization which is organized and operated exclusively for charitable, health or welfare services to the public and meets all of the following qualifications, as required by South Carolina Code of Laws Section 8-11-92: 1. Is and continues to be organized and qualified to solicit and operate under the laws of this state, pursuant to Chapter 56 of Title 33 of the South Carolina Code ("South Carolina Solicitation of Charitable Funds Act"); 2. Provides direct and continuing services to or on behalf of the citizens of South Carolina. For purposes of this section, "direct and continuing services" means: (a) services other than legal advocacy services which are provided directly to and specifically for one individual or one family; or, (b) services which are in the nature of medical research; or, (c) services which involve the collection and administration of funds by umbrella organizations for other organizations, all of which qualify under the Act; 3. Is recognized as tax exempt under Section 501(c)(3) of Title 26, United States Code (the Internal Revenue Code of 1954, as amended); 4. Is not an organization contemplated by Section 501(c)(4), 501(c)(5), or 501(c)(6) of Title 26, United States Code (the Internal Revenue Code of 1954, as amended) and is not an organization primarily engaged in the propagation of a religious faith or belief; this prohibition shall include, but not be limited to, organizations primarily engaged in lobbying or political activity; 5. Is operated without discrimination in regard to all persons served, and complies with all requirements of law, including administrative regulations, respecting non-discrimination and equal opportunity regarding its officers, staff, employees and volunteers; 6. Has neither a parent organization nor a subsidiary organization which fails to meet qualifications herein contained in items 1 through 5. _____________________________________ Name of Chief Executive Officer American LegalNet, Inc. www.FormsWorkFlow.com _____________________________________ Signature of Chief Executive Officer Application for Payroll Deduction, revised May 2012