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STATE OF SOUTH CAROLINA OFFICE OF THE SECRETARY OF STATE APPLICATION FOR PAYROLL DEDUCTION
All fundraising agencies should return this form and all attachments to: South Carolina Secretary of State Attn: Payroll Deductions Post Office Box 11350 Columbia, South Carolina 29211 **If you are a member organization of a fundraising agency, please forward your information to the fundraising agency rather than sending it directly to the Secretary of State's Office.
Name of Charitable Organization: ___________________________________________________________________ Charitable Organization's Registration Number: _________________________________________________________ Contact Person: ________________________________________________________________________________ Address: _____________________________________________________________________________________ Telephone: ____________________________________ Fax: __________________________________________

E-mail Address: ________________________________________________________________________________

I hereby certify that the above is a nonprofit, eleemosynary corporation, association or organization and is organized and operated exclusively for charitable, health or welfare services to the public and meets all of the following qualifications: 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 ("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. Sworn to and Subscribed before me: this ________ day of ___________, 20____ ___________________________________ Notary Public of South Carolina My Commission Expires:
Payroll Deduction Application

__________________________________________________ Signature of Chief Executive Officer __________________________________________________ Chief Executive Officer (Print Name) __________________________________________________ Date
Form Revised by South Carolina Secretary of State, April 2008