Form NEH Organizational NEH Organizational NEH Organizational Survey

OMB No. 3136-0134
Expires: 6/30/21

ORGANIZATIONAL SURVEY
Please respond to all items on this survey, and attach the relevant financial statements as requested on
the last page of the form.
A completed and signed copy of this survey, plus the attachment(s), should be returned to the NEH
Office of Grant Management either by scanning and e-mailing it to [email protected] or by
faxing it to (202) 606-8633.
Name of Applicant Organization
Provide the legal (registered) name of the applicant organization and the permanent street address and
telephone number.
Name:
Address:

Telephone No.:
List any commonly used name(s) of the applicant organization, and any Trade or Doing Business As
(DBA) name

Type of Organization
Incorporated, Nonprofit with IRS tax status 501(c) (3)
Incorporated, Commercial/For-Profit
Unincorporated, Nonprofit
Unit of State Government
Unit of Local Government
Federally Recognized Indian Tribal Government
College or University
Other. Provide Description:
Date organization established:
Date received IRS tax status 501(c)(3):

Date incorporated:

Is the applicant organization affiliated with any other organization, either for-profit or nonprofit?
Yes

No

If yes, list and describe the relationship with any affiliate organization, e.g., parent organization,
subsidiaries, or other affiliates. Please address whether there are overlapping board members and whether
tax returns are consolidated or separate. Please state whether the affiliate is a nonprofit, commercial, or
unincorporated business.

Does your organization share staff, premises, or equipment with other organizations or affiliates?
Yes

No

If yes, provide a description of this shared arrangement.

Purpose of Organization
Provide a description of the purpose of your organization. Include information on the number of
permanent, full-time employees, part-time employees and independent contractors.

Governing Board
Provide the name, title, and address for each of the persons comprising the governing board of your
organization.

Other Current Activities
Will this project be the only current activity of this organization?
Yes

No

If not, please provide a brief description of the other activities, projects or grants. Please list federal grants
and cooperative agreements received within the past two years.

Financial Statements
1. Has your organization had an organization-wide single audit in the last two years (see 2 CFR 200 Subpart F - Audit Requirements)? If so, please submit a copy of the single audit reporting package for
each of the two years.
2. If not, has your organization received a financial statement audit in the last two years in which an
independent audit firm opined on the statements? If so, please submit a copy of the audited financial
statements and independent auditor's reports for each of the two years, along with the contact
information of the engagement partner at the audit firm.
Additionally, for items 1 and 2 above, please provide a copy of the SAS-112/115 management
letters issued by the audit firm in conjunction with the annual audits.
3. If neither item 1 nor 2 applies, please explain why a formal audit was not performed. Additionally,
please submit your organization's latest tax return, (i.e., IRS Form 990 and 990-T) along with a set of
the organization's internal financial statements.
Application / Grant Number:
Prepared by (Printed Name and Title):
(Signature and Date)
NEH estimates the average time to complete this form is thirty minutes per response. This estimate includes the time for reviewing the
instructions for this form, gathering the necessary data and entering the data on the form. Please send any comments regarding this estimated
completion time or any other aspect of the form, including suggestions for reducing completion time, to the Director, Office of Publications,
National Endowment for the Humanities, Washington, D.C. 20506; and to the Office of Management and Budget, Paperwork Reduction
Project (3136-0134), Washington, D.C. 20503. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number.