A separate document must be submitted for each affiliated entity.

Email the affiliated entity documentation to nap@dss.virginia.gov by the NAP application deadline.

Part I

Name of Applicant Organization:
Name of Affiliated Entity:
Federal ID # of Affiliated Entity:
Affiliated Entity Mailing Address: PO Box or Street: City, State, Zip:
Affiliated Entity Phone Number:
Describe the affiliated entity’s programs. Explain how the affiliated entity is meeting the requirement of primarily providing assistance to low-income people in Virginia. Use additional pages as needed.
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.):

Certification of Income Levels Served

Name of Applicant Organization:
Name of Affiliated Entity:

To be completed by the each affiliated entity.

Complete the chart below using information on clients served for the calendar year 2023, FY 7/2022 – 6/2023, 10/2022 – 9/2023,
4/2022 – 5/2023, etc. Use unaudited numbers from the organization’s internal records for the revenue and expenses if the audit, review or compilation, or federal form 990 has not been finalized for the same period listed above.

The requested information must include all of the programs provided by the affiliated entity and reflect the total operation not just one or more programs conducted by the affiliated entity. 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 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:
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 affiliated entity 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 affiliated entity.
Add Lines 6 and 8. This is the total funds spent assisting or providing services to low-income people in Virginia.	$