The Sample Application is for the organization’s use only. The organization must enter the information into the VDSS NAP database between March 15, 2024 – May 1, 2024, by 5:00 p.m.

Refer to this application if you will be submitting an application for tax credits to the Virginia Department of Social Services (VDSS). The NAP database is only to be used by an organization submitting an application to VDSS for tax credits. The organization may only submit one application for NAP tax credits.

Send an email to tax.credits@doe.virginia.gov to apply for education tax credits with the Department of Education. DOE has a separate application process.

Non-Profit Organization (NPO) Profile

NOTE: The NPO Profile information must be updated through the “Manage Profile” page of the online application prior to accessing the application. The NPO Profile information listed in the application pulls from the Manage Profile screens and cannot be changed through the NPO Application screen. Click on submit ONLY AFTER reviewing/updating all of the pages – profile, description of programs, mission statement and attachments.

Part I – NPO Profile

Federal ID #:
Date 501(c) (3) Status was Received:
Organization Name:
Business Mailing Address: PO Box or Street: City, State, Zip:
Phone Number:
Fax Number:
City/County of Main Office:
Web Address:
Contact 1 - Executive Director or CEO: Name: Title: Phone Number: Email address:	Mr. Ms. Mrs. Dr.
Contact 2 - Contact Person for NAP: Person responsible for entering donations into the database. Name: Title: Phone Number: Email address:	Mr. Ms. Mrs. Dr.

Non-Profit Organization (NPO) Profile

NOTE: The NPO Profile information must be updated through the “Manage Profile” page of the online application prior to accessing the application. Click on submit ONLY AFTER reviewing/updating all of the pages – profile, description of programs, mission statement and attachments.

Name of Applicant Organization:

Part I – NPO Profile

Describe the organization’s programs. The requested information must include all the programs within the organization and reflects the total operation of the organization, not just one or more programs conducted by the organization. Use the Federal Poverty Guidelines chart, provided in the instructions, to determine the income levels of people served.

Describe the organization’s programs. Explain how the organization is meeting the requirement of primarily providing assistance to low-income people in Virginia. (Limited to 2000 characters, use additional pages as needed. Upload the additional pages in a PDF format in the “Attachments” section of the organization’s online profile).
List the Mission Statement and date adopted by Board, if applicable (If the Mission Statement is different from the description shown in the audit report, review, or compilation, please explains.) (Limited to 1000 characters, use additional pages as needed. Upload the additional pages in a PDF format in the “Attachments” section of the organization’s online profile).

Click on save AFTER EACH page of the online application. Review the message at the top of the page to ensure the information is saved and there is no error message.

NPO Application - General InformatioN page

Name of Applicant Organization:

Part II – NPO Application

Enter the anticipated amount of NAP eligible donations the organization expects to receive from 7/1/2024 – 6/30/2025 to support low-income people. The NAP database will automatically calculate the amount of tax credits at 65% of the anticipated amount of donations the organization expects to receive. $
GOALS OBJECTIVES Provide a statement of the organization’s program goals/objectives. List the outcomes/accomplishments that are expected to occur during FY 2024-2025 for ALL of the organization’s programs. Discuss the method that will be used to evaluate the program’s effectiveness. (Limited to 2000 characters, use additional pages as needed. Upload all additional pages in a PDF format in the “Attachments” section of the online application). NOTE: An evaluation report listing the program outcomes will be required at the end of the fiscal year for an organization receiving an allocation of NAP tax credits. The report is due by July 31st each year. Email the report to nap@dss.virginia.gov. The report must include - goals listed in the fiscal year application; accomplishments; the number of people served at or below 200% of the federal poverty guidelines (FPG), the number of people served at or below 300% of the FPG; and the number of people served not reported at the 200% or 300% FPG levels.

NOTE: Click on save AFTER EACH page of the online application. Review the message at the top of the page to ensure the information is saved and there is no error message.

NPO APPlication - General InformatioN page

Name of Applicant Organization:

Types of Services Offered (Select all that apply)
AIDS Program Related Services	Child Care Programs
Comprehensive Emergency Services	Court Referred Mediation Services
Economic Revitalization Project	Education/Scholarship/Scholastic Assistance
Ex-Offender Services	Food Bank (an organization that provides food to other non-profit organizations.) (Select “other” if the organization provides food directly to low-income clients).
Health Care Services	Homeless Shelter
Homes/Center for the Disabled	Housing
Job Training/Employment Services	Legal Services
Literacy Programs	Other
Programs Related to the Arts	Senior Citizens Services
Specialty Medical Referral Services	Substance Abuse Counseling
Teen Pregnancy/Family Planning/Counseling	Transportation Services
Utility Companies	Water/Wastewater Program
Youth Activities/Youth Center	Youth/Domestic Violence Shelter
Does this organization operate an on-site health care clinic? If yes, describe the type and frequency of services. (Limited to 2000 characters, use additional pages as needed. Upload all additional pages in a PDF format in the “Attachments” section of the online application). Yes No
Did this organization merge with another VDSS NAP organization within the previous four years? Yes No If yes, enter the Federal Tax ID number and list name of other organization.
Does this organization have any affiliated entities indicated in the audit, review or compilation report? Yes No If yes, list the name(s) of each affiliated entity: Additional application information will be required.

NOTE: Click on save AFTER EACH page of the online application. Review the message at the top of the page to ensure the information is saved and there is no error message.

Please check all localities in which the organization will actively provide services. If the organization provides statewide services, check here: Statewide Services
Accomack	Albemarle	Alexandria City	Alleghany	Amelia
Amherst	Appomattox	Arlington	Augusta	Bath
Bedford (Bedford City)	Bland	Botetourt	Bristol	Brunswick
Buchanan	Buckingham	Buena Vista	Campbell	Caroline
Carol	Charles City	Charlotte	Charlottesville	Chesapeake
Chesterfield	Clarke	Colonial Beach	Colonial Heights	Covington
Craig	Culpeper	Cumberland	Danville	Dickenson
Dinwiddie	Emporia	Essex	Fairfax	Falls Church
Fauquier	Floyd	Fluvanna	Franklin	Franklin City
Frederick	Fredericksburg	Galax	Giles	Gloucester
Goochland	Grayson	Greene	Greensville	Halifax
Hampton	Hanover	Harrisonburg	Henrico	Henry
Highland	Hopewell	Isle of Wight	James City	King George
King William	King & Queen	Lancaster	Lee	Lexington
Loudoun	Louisa	Lunenburg	Lynchburg	Madison
Manassas	Manassas Park	Martinsville	Mathews	Mecklenburg
Middlesex	Montgomery	Nelson	New Kent	Newport News
Norfolk	Northampton	Northumberland	Norton	Nottoway
Orange	Page	Patrick	Petersburg	Pittsylvania
Poquoson	Portsmouth	Powhatan	Prince Edward	Prince George
Prince William	Pulaski	Radford	Rappahannock	Richmond
Richmond City	Roanoke	Roanoke City	Rockbridge	Rockingham
Russell	Salem	Scott	Shenandoah	Smyth
South Boston	Southampton	Spotsylvania	Stafford	Staunton
Suffolk	Surry	Sussex	Tazewell	Virginia Beach
Warren	Washington	Waynesboro	Westmoreland	West Point
Williamsburg	Winchester	Wise	Wythe	York

NOTE: Click on save AFTER EACH page of the online application. Review the message at the top left-hand side of the page to ensure the information is saved and there is no error message.

Name of Applicant Organization:

CERTIFICATION OF INCOME LEVELS SERVED – NPO APPLICATON

The requested information must include all the programs within the organization and reflect the total operation of the organization, not just one or more programs conducted by the organization.

Total family’s annual household income includes wages/salaries, social security income, pensions, dividend/interest income, SSI, etc.

Describe the data, resources, procedures and methodology used to determine the income levels of the total persons served. Be specific about what data is used to determine if the person served has a household income that is not in excess of 300 percent of the federal poverty guidelines, and how this data is acquired. (Limited to 1000 characters, use additional pages as needed. Upload all additional pages in a PDF format in the “Attachments” section of the online application).
Describe how often the household income information is updated. (Limited to 1000 characters, use additional pages as needed. Upload all additional pages in a PDF format in the “Attachments” section of the online application).
If the population you currently serve has changed and does not mirror the information listed in Certification of Income Levels table, please explain. (If not applicable, write N/A) (Limited to 1000 characters, use additional pages as needed. Upload all additional pages in a PDF format in the “Attachments” section of the online application).

NOTE: Click on save AFTER EACH page of the online application. Review the message at the top of the page to ensure the information is saved and there is no error message.

Certification of Income Levels Served – NPO APPlication

Complete the table below using information on clients served for calendar year 2023, FY 7/2022 – 6/2023, 10/2022 – 9/2023, 4/2022 – 5/2023, etc. For the revenue and expenses sections, use unaudited numbers from the organization’s internal records if the audit, review, compilation or federal form 990 has not been finalized for the same dates listed above. The application will not be reviewed until the deadline to submit the audit has passed.

For new applicants, the time periods that may be used for determining the number of low-income persons served by your organization include (i) the most recent calendar year ended, (2023), (ii) completed program year (2022 - 2023), or (iii) 10/22 – 9/23 or the organization’s most recent fiscal year ended.

For returning applicants, the time period for determining the number of low-income persons served by the organization must be the same period used for last year’s application.

Note: The time period for determining the number of low-income persons served cannot be for any period after the submission date of this application.)

The requested information must include all of the programs within the organization and reflect the total operation of the organization, not just one or more programs conducted by the organization. If an individual received more than one type of service, only count the person once – this an unduplicated count.

Total family’s annual household income includes wages/salaries, social security income, pensions, dividend/interest income, SSI, etc.

Enter the Total Revenue reported on the most recent year ended audit or Federal Form 990 as indicated above.	$
Enter the total Expenses reported on the most recent year ended audit or Federal Form 990 as indicated above.	$
Enter the total number of people assisted by or using services for all of the programs provided by the organization during the most recent calendar year, program year, or fiscal year.
Enter the total funds spent in assisting or providing services for all of the programs provided to people during the most recent calendar year, program year, or fiscal year.	$
Enter the number of people served in Virginia whose family’s annual household income is at or below 200% of the federal poverty guidelines (FPG).
Enter the total funds spent in assisting or providing services to people in Virginia whose family’s annual household income is at or below 200% of the FPG.	$
Enter the total number of people served in Virginia whose family’s annual household income is above 200% but at or below 300% of the FPG.
Enter the total funds spent in assisting or providing services to people in Virginia whose family’s annual household income is above 200% but at or below 300% of the FPG.	$
Enter the number of people served outside of Virginia whose family’s annual household income is at or below 300% of the FPG.
Enter the total funds spent in assisting or providing services to people outside of Virginia whose family’s annual household income is at or below 300% of the FPG.	$
Add Lines 5 and 7. This is the total number of low-income people in Virginia assisted by or using services provided by the organization.
Add Lines 6 and 8. This is the total funds spent assisting or providing services to low-income people in Virginia.	$

Enter the time period used to complete the table from the most recent year ended audit, review or compilation or Federal Form 990 for the dates indicated above.	Start Date:
End Date:

NOTE: Click on save AFTER EACH page of the online application. Review the message at the top of the page to ensure the information is saved and there is no error message.

CERTIFICATION OF INCOME LEVELS SERVED – NPO APPLICATION

FOR USE BY FOOD BANKS - TYPES OF ORGANIZATIONS RECEIVING FOOD

Complete the table below using information on clients served for calendar year 2023, FY 7/2022 – 6/2023, 10/2022 – 9/2023, 4/2022 – 5/2023, etc. For the revenue and expenses sections, use unaudited numbers from the organization’s internal records if the audit, review, compilation or federal form 990 has not been finalized for the same dates listed above. The application will not be reviewed until the deadline to submit the audit has passed.

For new applicants, the time periods that may be used for determining the number of low-income persons served by your organization include (i) the most recent calendar year ended, (2023), (ii) completed program year (2022-2023), or (iii) 10/22 – 9/2023, or the organization’s most recent fiscal year ended.

For returning applicants, the time period for determining the number of low-income persons served by the organization must be the same period used for last year’s application.

Note: The time period for determining the number of low-income persons served cannot be for any period after the submission date of this application.)

The requested information must include all of the programs within the organization and reflect the total operation of the organization, not just one or more programs conducted by the organization.

Enter the Total Revenue reported on the most recent year ended audit or Federal Form 990 as indicated above.	$
Enter the total Expenses reported on the most recent year ended audit or Federal Form 990 as indicated above.	$
Enter the total number of agencies receiving food from the organization during the most recent calendar year, program year, or fiscal year.
Enter the total funds spent providing food to agencies during the most recent calendar year, program year, or fiscal year.
Enter the total pounds of food provided by the organization during the most recent calendar year, program year, or fiscal year.	$
Enter the number of agencies providing services to people in Virginia whose family’s annual household income is at or below 200% of the federal poverty guidelines (FPG).
Enter the total funds spent providing food to agencies that provided services to people in Virginia whose family’s annual household income is at or below 200% of the FPG.	$
Enter the number of agencies providing services to people in Virginia whose family’s annual household income is above 200% but at or below 300% of the FPG.
Enter the total funds spent providing food to agencies that provided services to people in Virginia whose household income is above 200% but at or below 300% of the FPG.	$
Enter the number of agencies providing services to people outside of Virginia whose family’s annual household income is at or below 300% of the FPG.
Enter the total funds spent providing food to agencies that provided services to people outside of Virginia whose family’s annual household income is at or below 300% of the FPG.	$
Add Lines 6 and 8. This is the total number of agencies receiving food that provided services to low-income people in Virginia.
Add Lines 7 and 9. This is the total funds spent providing food to agencies that provided services to low-income people in Virginia.	$
Enter the time period used to complete the table from the most recent year ended audit, review or compilation or Federal Form 990 for the dates indicated above.	Start Date:
End Date:

NOTE: Click on save AFTER EACH page of the online application. Review the message at the top of the page to ensure the information is saved and there is no error message.

AGENCIES SERVED

FOR USE BY FOOD BANKS

Name of Applicant Organization:

Please list the name of the agencies receiving food from the organization during the past year. Upload all pages in a PDF format in the “Attachments” section of the online application).

NOTE: Click on save AFTER EACH page of the online application. Review the message at the top of the page to ensure the information is saved and there is no error message.

ASSURANCE STATEMENT

I, the undersigned officer or other person authorized to act on behalf of the organization, declare that this form (including all accompanying attachments and documentation) is, to the best of my knowledge and belief, a true, correct and complete application, made in good faith pursuant to the requirements prescribed by the Virginia Department of Social Services. I understand this application will be denied if not received by the due date or if any part of the application is missing or incomplete.

I assure the Virginia Department of Social Services that any tax credit-derived donations received under the Neighborhood Assistance Act Tax Credit Program will be used to provide services to low-income persons residing in the Commonwealth of Virginia whose family’s annual household income is not in excess of 300 percent of the current federal poverty guidelines, collecting all necessary documentation that demonstrates compliance with the household income requirements.

I understand that participating in NAP obligates my organization to keep donor records confidential; work with the donors to assure a timely and accurate completion and submission of the Contribution Notification Forms (CNFs) including supporting documentation for all donations; maintain in my facility and make records pertaining to NAP transactions available to VDSS for a period of five (5) years; and abide by all applicable NAP laws and VDSS regulations.

Date Name / Title Signature and Title