National Council on Problem GamblingAffiliate Membership Renewal 2019

Affiliate Members are non-profit organizations that support and implement the purpose, mission and goals of the NCPG, and serve as the official representative of NCPG in their respective state(s). Affiliate Membership is a status of Membership separate from and different than either Individual or Organizational Membership in the National Council on Problem Gambling (NCPG).

The goal of the NCPG Affiliates Membership program is to have an active and effective Affiliate chapter in each state, providing meaningful programs and services to people affected by problem gambling. As representatives of the national association, all Affiliates are required to meet or exceed the following standards:

AFFILIATE MEMBERSHIP STANDARDS

At all times during its membership, an Affiliate Member is expected to:

1. Have a principal office in the state it represents and maintain a working phone number and email address;

2. Be legally qualified as a Federal 501(c)(3) non-profit entity and meet all required city, state and federal business and nonprofit requirements, as applicable;

3. Have a Board of Directors that represents a broad cross-section of stakeholders on gambling issues and convenes at least one time per year;

4. Have a written policy statement that the organization is neither for nor against legalized gambling;

5. Have the duty to advocate for programs to assist anyone affected by problem gambling; and

6. Demonstrate the capacity to provide programs and services for those affected by problem gambling.

AFFILIATE ANNUAL MEMBERSHIP RENEWAL

Please refer to your current copy of the Affiliates Standards, Renewal and Application Policy for complete details.

--Affiliates must complete the renewal process. All affiliate memberships that are not renewed expire on May 31 each year.

--In extraordinary circumstances, affiliates may request an extension of time to complete the renewal documents or pay dues; or request a reduction of dues. This must be done in writing by April 30. Even if a dues reduction is granted, affiliates must still submit the renewal form and documents.

Requirements for Renewal:

1. Maintain all standards and requirements set forth in the Affiliate Standards Policy, and any additional requirements that are listed in the current Affiliate New Member Application here:

. 

2. Make timely payment of annual dues as determined by the NCPG Board of Directors, or submit a written request for reduction of annual dues in a form stipulated by the NCPG Board of Directors.

3. Provide the following to NCPG by April 30:

· The completed Affiliate Renewal Application, and all documentation required by the application.

· A copy of the applicable IRS Form 990, 990-PF,999A, 990EZ, or 990-N (postcard) as submitted to the IRS by the Affiliate, covering the Affiliate’s tax year completed as of two years earlier (for example, for your renewal due April 30, 2018, you would submit your taxes from your FY2016, which for most affiliates would have an ending date of 12/31/16 or 6/30/16).

4. Please note: you must include the 990 from your 2017 fiscal year. The ending date must be in 2017. The form number and date in the upper right corner could say 2016, 2017 or 2018.

You should compose your responses first as a separate document and then copy and paste them into the online form. You will be able to save your work in the online form and return to it later but only via a link in your confirmation email. Sometimes this is not 100% reliable depending on which browser and what version of it you are using - in particular, we recommend that you do NOT use Internet Explorer. But if you compile your responses separately first, you will not lose your work. If necessary, you can also use a Word document version of the form and return it by mail or email.

REQUIRED DOCUMENTS

· Board list, detailing officers and contact info

· Staff list, including contact info (if applicable)

· IRS 501(c)(3) letter

· Mission statement and statement of neutrality

· Budget allocation to activities

· 990 or applicable version of it (from your FY2017)

Optional documents

· Annual report or list of activities from your most recently completed fiscal year, probably ending 6/30/18 or 12/31/18.

Basic Information

Please use current, updated information for these fields.

Affiliate Organization Name*

Other: Click here to enter text.

Mailing Address*

Address Line 1

Address Line 2

Shipping Address (if different from mailing address)

Address Line 1

Address Line 2

Directory Information ( this information is given on NCPG website and elsewhere as a help resource)*

Directory Address*

Address Line 1

Address Line 2

Directory Website*

Click here to enter text.

Helpline/Directory Phone Number *

Click here to enter text.

Does the Affiliate maintain an active business email address?*

☐ Yes☐ No

If yes, please supply it here*Click here to enter text.

Please confirm your information as displayed on NCPG’s websiteOne of your benefits as an Affiliate is having your organization's contact information shared on our Help By State pages. Please visit the page now and review your section.

https://www.ncpgambling.org/help-treatment/help-by-state/

*Are there any changes to be made to your information?

☐ Yes☐ No

If yes, please supply the information you want shown.Click here to enter text.

Is the principal Affiliate office located in the state it represents? *

☐ Yes☐ No

Is the Affiliate a Federally-recognized 501(c)(3) not-for-profit organization?*

☐ Yes☐ No

Your Federal Tax ID/EIN*Click here to enter text.

Is the Affiliate incorporated as a non-profit organization in the state that it represents?*

☐ Yes☐ No

Your State Tax ID/EIN (if different from your Federal EIN) Click here to enter text.

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Representative & Alternate

Each Affiliate is required to have an official Representative to serve as the main conduit of information and communication. The Representative becomes an ex officio Member of NCPG and receives the same membership benefits as an Individual Plus Member except that these benefits end when the Representative steps down.

Each Affiliate should have an Alternate Representative. The Alternate Representative steps in when the Representative is not available. The Alternate is required to have an NCPG membership of some type.

The Representative and Alternate should plan to serve for the full Affiliate membership year (June 1 to May 31).

In the event that either person changes during the year, you will need to inform NCPG in writing on the Change of Affiliate Rep form (provided upon request). If the Representative steps down, that person also releases their member benefits.

The Alternate substitutes for the Representative when deemed necessary and may vote on Affiliates Committee matters on behalf of the Affiliate in the Representative's absence.

*Please note: As of December 2016, the Alternate must be an NCPG Member.

Affiliate Representative - Contact Information*

Name:Title:Email:Phone:

Affiliate Alternate - Contact InformationName:Title:Email:Phone:

Alternate's NCPG Membership Expiration Date (if known) Click here to enter text.

Staff

Please provide a complete list of staff names and contact information, including titles, phone numbers, and email addresses. You can attach a staff list or create a list below.

First name

Last name

Title

Email

Phone

We do not have any paid staff

Affiliate's Primary Staff ContactName:Title:Email:Phone:

Board of Directors

Number of board meetings held during your most recently completed fiscal year.*

Click here to enter text.

Please provide a complete list of your Affiliate’s Board of Directors, including names, titles, phone numbers, and email addresses. Please include Board Officer titles. This is required, pursuant to the NCPG Bylaws.

Include Officer information in the ‘title’ column.Positions marked with * are required. You can attach a list or create a list below.

First name

Last name

Officer/Title

Email

Phone

President*

Vice President

Secretary

Treasurer*

Director

Mission and Neutrality Statements

Please provide your mission statement and statement of neutrality on legalized gambling. If your role or duty in advocating for services for problem gamblers and their families and your statement of neutrality is not included in your mission statement, please include separate statements to that effect as well.

Click here to enter text.

Annual Report or Completed Activities

Please attach or paste below your most recent annual report or list of activities in your most recently completed fiscal year (ending date in 2018). This can be a simple list. If you include a report on Helpline services, please submit only a summary.

Click here to enter text.

Services

Please check all services you provide.

Helpline

Research

Recovery

Public Awareness

Treatment

Prevention

Counselor Certification/Training

Responsible Gaming

Other ServicesClick here to enter text.

Helpline Services

Do you utilize the National Helpline Number (800-522-4700) as your primary helpline number?*

☐ Yes☐ No

Do you reimburse NCPG for calls from your state to the National Helpline Number?*

☐ Yes☐ No

Do you provide Helpline services via text message?*

☐ Yes☐ No

Do you provide Helpline services via online chat?*

☐ Yes☐ No

Percent of Budget Allocated To:

Please provide your budgeted allocation to activities by percentage of the whole. Use your most recently completed fiscal year, if applicable. Otherwise, use your planned budget.The total of budget categories must sum to 100.

Helpline: ___% 

Treatment: ___%

Research: ___%

Prevention: ___%

Recovery:___%

Certification/Training: ___%

Public Awareness: ___%

Responsible Gaming: ___%

Administration & Overhead: ___%

Other: ___%

Total (must = 100%):___%

Other / CommentsClick here to enter text.

Public Awareness and Prevention Services

Did you participate in National Problem Gambling Awareness Month (NPGAM) last year (2017)?

☐ Yes☐ No

Advocacy

Have you contacted your state legislators and/or executive branch on a gambling-related bill or this issue in the past 12 months?

☐ Yes☐ No

Has a state legislator or member of the executive branch contacted you on a gambling-related bill or issue in the 12 months?

☐ Yes☐ No

Was there a bill in your state legislature to expand in the past 12 months?

☐ Yes☐ No

If yes, did the state bill(s) pass?

☐ Yes☐ No

Have you contacted your Federal representatives on a gambling-related bill or issue in the past 12 months?

☐ Yes☐ No

Accomplishments

What are the top three accomplishments of your Affiliate in the last year? Note: 500 words maximum, each:

Accomplishment #1 

Accomplishment #2 

Accomplishment #3 

Assistance

What are the top three things for which your Affiliate might want assistance from NCPG? Note: 500 words maximum, each:

Assistance #1 

Assistance #2 

Assistance #3 

Legal and Financial Information

*Please provide a copy of your IRS 501(c)(3) letter.

IRS tax return for your FY2016Pursuant to Section 3.2 of the NCPG Bylaws, Affiliate members must verify and provide their financial information by attaching one of the following IRS Forms: Form 990, 990-PF,999A, 990EZ, or 990-N (postcard).

Please choose only one. Please submit the form that applies to your FY2016. For most, this will be the fiscal year ending 6/30/16 or 12/31/16. The IRS form could have 2016, 2017 or 2018 in the upper right corner. The form should appear as submitted to the IRS by the Affiliate, including signature and date.

Type of IRS Form attached (mark only one)*

☐ 990

☐ 990EZ

☐ 990-PF

☐ 990A

☐ 990-N (electronic postcard)

Starting date of the fiscal year to which your submitted form applies? This should reflect your 2017 fiscal year. mm/dd/yyyy 

Ending Date of the fiscal year to which your submitted form applies? This should reflect your 2017 fiscal year. mm/dd/yyyy *

Gross Revenue and Dues Payment

Affiliates dues are currently based on roughly 1% of your operating budget gross revenue, as shown on the submitted 990, with a minimum of $100 and a maximum of $5,000. The dues table below is current for 2019. Dues must be paid by May 31 of the year. Contact NCPG if you have questions.

Annual Gross Revenue ($) as reported on your attached 990. Income includes grants, program fees, sponsorships, membership dues, and any other types of revenue. For those who use the full Form 990, it would be Line 12 (in the column for current year)*

Click here to enter text.

Affiliate Dues ScheduleAnnual Gross Revenue RangeDues$500,000 and above$5,000$450,000 to $499,999$4,500$400,000 to $449,999$4,000$350,000 to $399,999$3,500$300,000 to $349,999$3,000$250,000 to $299,999$2,500$200,000 to $249,999$2,000$150,000 to $199,999$1,500$100,000 to $149,999$1,000$50,000 to $ 99,999$ 500$0 to $ 49,999$ 100

Based upon the information above, what is the dues amount that you are paying this year?*

$________

Have the dues already been paid?*

☐ Yes, check #   and date mailed or paid mm/dd/yyyy

☐No, intended date of payment is mm/dd/yyyy

Please note: the deadline for payment of Affiliate dues is May 31, 2019. Please make checks payable to “National Council on Problem Gambling.” Dues may be paid online with assistance from NCPG staff - please call us for help in setting this up or making payment by phone.

Attestation

I hereby attest that all information provided here is accurate and up to date.

Submitted by:*Name:

Title:

Date:

Finish

Thank you for submitting your Affiliate Membership renewal! Be sure to look for and save an email confirming receipt of your completed form. It may get routed into your junk mail.

If necessary, you may mail, fax, or email this form and supporting documents to:

National Council on Problem Gambling Attn: Affiliates Committee 730 11th St, Suite 601Washington, DC 20001ncpg@ncpgambling.orgPhone: 202-547-9204Fax: 202-547-9206

For questions regarding the content of this form, contact Affiliate Committee Chair Derek Longmeier (dlongmeier@pgnohio.org) or NCPG Executive Director Keith Whyte (keithw@ncpgambling.org).

For questions about submitting the form, contact Deanna Wilken, Communications Manager (ncpg@ncpgambling.org).

Please note:

Affiliates must complete the renewal process by submitting their renewal form and supporting documents by April 30 to maintain membership for the next year. Payment of dues must be completed by May 31 each year.

In extraordinary circumstances, you may request an extension of time to complete the renewal documents or pay dues; or a reduction of dues. This must be done in writing by April 30. Even if a dues reduction is granted, you must still submit your renewal form and documents by April 30.

Any affiliate memberships that are not renewed expire on May 31 unless an extension has been formally requested and approved.