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Home Away From Home Tax Credit Application

Contact Division of Children's Medical Services

Date of Application:

Application Designation:Initial Redesignation

Organization Name:

FEIN:

Exemption Income Tax Number:

Executive Director/CEO:

Principal Office Physical Address (Street, City, State, Zip):

Mailing Address (Street, City, State, Zip):

Phone Number:

Email Address:

Website Address:

Organization Primary Contact:

Primary Mailing Address:

Primary Phone Number:

Primary Email Address:

Organization Description:

Services Offered:

Number of Individuals Served During Last Calendar Year:

Describe how the Eligible Charitable Organization plans to expend the contributions received under s. 402.63, Florida Statutes, for either the expansion of current structures or the construction of new facilities:

Projected Cost of the expansion of current structures or construction of new facilties (USD):

Enter the amount in US dollars.

Proposed Project Start Date:

Proposed Project End Date:

Background Screening:

Eligible Charitable Organizations must apply for admittance into the Department of Law Enforcement's Volunteer and Employee Criminal History System and, if accepted, conduct background screening on all volunteers and staff working directly with children in any program funded under this section pursuant to s. 943.0542, Florida Statutes. In accordance with s. 435.04, Florida Statutes, all employees and volunteers shall be required to undergo a level 2 security background screening which includes, but is not limited to fingerprinting for a state, national, and local criminal history records check, as well as a check of the Dru Sjodin National Sex Offender Public Website.

The Department of Health will verify background screening results through the Florida Department of Law Enforcement (FDLE), Volunteer & Employee Criminal History System (VECHS) Program.

Applicant acknowledges and agrees to terms of background screening requirement.

Attestation:

I certify that all data and documents submitted for the Home Away from Home Tax Credit Eligible Charitable Organization designation are accurate, truthful, and complete to the best of my knowledge, information, and belief. I attest under penalty of perjury that I am a current officer of the organization submitting an initial designation or redesignation application for the Home Away from Home Tax Credit Eligible Charitable Organization. I attest that the organization meets all criteria to qualify as an eligible organization. Finally, I attest that my organization does not provide abortions or pays for or provides coverage for abortions.

Printed Name:Title:Date: