2016 Agency Verification Form

United Way of the Mid-Willamette Valley offers our donors the option to direct gifts to eligible organizations operating in the State of Oregon.  If United Way has received a designated gift to your organization, you will be notified by us.  This form is only required if you have received notification from United Way of the Mid-Willamette Valley.

In order to be eligible to receive the donor designated gift, your organization must have a current 501(c)(3) tax exempt status, a Form 990 filed with the Internal Revenue Service (unless you are a church), and be in compliance with the USA PATRIOT Act and other counter-terrorism laws.  This form is used annually to establish your eligibility to receive donor directed funds from United Way of the Mid-Willamette Valley.  Read United Way of the Mid-Willamette Valley's Designation Policy.

United Way conducts an annual agency verification process that is aligned with our fiscal year.  This agency verification form is required for donor designated gifts that are made from July 1, 2016 - June 30, 2017.  If you have questions please contact Sherry Lintner.

Finance or Contact Person for Donations

Name of Person Completing Form

501(c)3 Determination Letter

Files must be less than 2 MB.
Allowed file types: jpg jpeg png txt pdf doc docx ppt pptx xls xlsx.

Form 990

Files must be less than 2 MB.
Allowed file types: gif jpg png txt pdf doc docx ppt pptx xls xlsx.

Anti-Terrorism Compliance

In compliance with the USA PATRIOT Act and other counterterrorism laws, United Way of the Mid-Willamette Valley requires that each organization certify the following:

“I hereby certify on behalf of my organization that all United Way funds and donations will be used in compliance with all applicable anti-terrorists financing and asset controls laws, statutes and executive orders.”

Thank you for your prompt response!