Questionnaire for governmental units

As part of our commitment to sound stewardship, Thrivent Charitable Impact & Investing must periodically confirm the charitable status of organizations receiving grant distributions through Thrivent Charitable charitable funds. To confirm your organization's charitable status and receive future grant distributions, please complete this questionnaire and return it to Thrivent Charitable. The following information helps determine your entity's eligibility to receive a grant from Thrivent Charitable, a section 50 7 (c)(3) charitable organization.

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*Legal Name of Governmental Unit

*Street address

*City

*State

*ZIP code

Tax ID number (if any)

Date unit was formed

*Contact person

*Phone

*Website

*Email

Basis for governmental status

Please check the box that best describes the entity.

*Type of entity

Political subdivision of a government unit (geographical). This applies to separate geographically-based jurisdictions (including states, counties, townships, cities, towns, villages, and so forth).

Political subdivision of a government unit (other special functions). This applies to other separate governmental entities that have been delegated significant sovereign powers of the state (such as the right to collect taxes, exercise police powers, or seize property by eminent domain). For instance, port authorities, school boards, public utility regulatory bodies, and similar bodies might qualify to check this box.

It is an "integral part" of a government or of a political subdivision. This applies to agencies, departments, divisions, and other offices within a government unit that are not treated as separate corporate entities under local law. It may also include separately incorporated entities if they are completely dominated by and significantly funded by a government unit.

It is a "wholly-owned instrumentality" of the government. This includes other government-controlled entities that are treated as separate corporations and serve a governmental purpose. They are typically subject to special government oversight and have a close financial connection with the government.

Other

If other, please describe.

If the entity has an IRS letter currently in effect recognizing it as the type of entity selected above, please attach a copy. Please also attach any other IRS letters that indicate a connection to government (e.g., section 115 of the Code).

Choose file

Please describe the specific charitable project for which you would use Thrivent Charitable's grant money (an estimated $).

Charitable purposes include alleviating poverty, preserving the community, providing parks, education, and other similar efforts that relieve the burdens of government.

Is the entity a separate legal unit, or is it an internal division of a larger government entity?

Has the organization received exempt status under section 501 (c) of the Internal Revenue Code?

If so, please attach a copy of its IRS exemption letter, if available.

Choose file

If the organization is a municipal corporation or a similar geographic subdivision of a larger governmental unit, please provide a hyperlink for a current copy of that larger governmental unit's official list of smaller subdivisions.

You may then skip to the signature section of this form.

Describe how the entity was formed: Was it formed by special legislation, regulation, executive order, or similar governmental act, or was it formed under a general incorporation statute? In either case, include a copy of the formation document (e.g., Articles of Incorporation or special legislation or ordinance creating the entity).0/150

Does the entity serve a governmental function or purpose or act on behalf of government entities? If so, please explain.0/150

Does a governmental unit directly or indirectly control the entity (for example, because government officials appoint its board of directors or chief officer or serve in those roles themselves)? Explain any control that the governmental unit has over the entity, and provide copies of bylaws or similar documents that demonstrate this control relationship. Besides governance control, please indicate other forms of governmental supervision (for instance, if the entity is subject to audit by the state comptroller).0/150

Does the organization exercise significant sovereign powers, such as imposing taxes, imposing punishments for failure to comply with government rules, issuing subpoenas, or condemning property through eminent domain? If so, please describe.0/150

Describe whether there are any private interests involved in your organization (e.g., private shareholders or accountholders, or private industry representatives).0/150

If a governmental unit exercises any other forms of supervision over the entity (for instance, by performing a regular governmental audit, requiring reports on the use of governmental grant funds, etc.), describe that oversight here.0/150

What would happen to the entity's assets if the entity were dissolved? Would its assets revert to the government, or would their disposition be controlled by the government?0/150

Explain what portion of the entity's annual budget comes from governmental sources, and identify those sources. Also explain any initial or ongoing governmental contribution of substantial assets or facilities to the entity. Do any of the entity's major capital assets come from the government?0/150

Are there any other factors not covered above that demonstrate that the entity is a governmental entity? (For example, are the entity's employees treated as state employees, its debts treated as obligations of the government, etc.?)0/150

*Acknowledgement

I declare that I am duly authorized to act on behalf of this entity and that to the best of my knowledge, the information provided is true and complete.

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Questionnaire for governmental units