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G-B 1. Is the organization exempt from ta~pursuant to Sec. 501 (c) of the Internal Revenue Cod~ of 19547 Yes X No G-B 2. Has a current annual alcoholic beverage license for serving alcoholic beverages been issued by the A)aC Board to such organization for use on such property? Yes No X _ G-B 3. Is any director or officer of the organization paid compensation or salary in excess of a reasonab"f~ allowance for services which such persons actually render? Yes No X If yes, explain: G-B 4. Yes~ Does any part of the net earnings of such organization subscribe to the ben~efit of any individual? No X . If yes, Explain. Is any significant portion of the service provided by such organization generated by funds received from donations, contributions, or local, state, or federal grants? As used herein, donations shall include the providing of personal services or the contributions of in-kind or material services. Yes X No. G-B 5. Does the organization provide services for the common good of the public? Yes X No G--B 6. Does a substantial part of the activities of the organization involve :arrying on propaganda, or otherwise attempting to influence legislation, aJ~d does the organization participate hi, or intervene in. any political cam- paign on behalf of any candidate for public office? Yes No. X G-B 7. Does any rule, regulation, policy or practice of the organization discriminate on the basis of religious convictions, race, color, sex, or national origin? Yes No 37 The resolution to be adopted must state that the provisions noted above have been examined and considered by the local governing body, and same would then be forwarded to the appropriate representatives in the General Assembly for presentation to the chairman of the committee before whom the legislation is pending. Prior to consideration by the committee of any such legislation, the committee chairman must determine that the local-government entity wb.-e the property is situated supports or refuses to support the exemption, or, if no action had been taken, that a formal., j. tin/ely request had oeen made to the governing body and that the governing body had faile&to act on the reques¥or otherwise refused to adopt the resolution. The enactment of a statute by the General Assembly exempting the organi- zation from taxation by designation is conclusive proof that the provisions of the section had been satisfied. ORGANIZATION Girls Incorporated Center for Youth of Southwest Hampton Roads BY: NAM_~-~t~chei_.le Jglmso~ T(.TiTLE Executive Director DATE October 13, 1994 STATE OF VIRGINIA SS, CITY OF PORTSMOUTH ~" ~'NXx~- ' ' ~ ~'x~ x"-~'"'-' being duly sworn, deposes and says that ~is the ~-."~ e._ ca~ .Ae~ ~'\ ~r,, ~l,.xt~ of the {TITLE) (kEO~k NAME OF OWNE~HtP ORaANIZAi:iON) ' ' - ' named wl~m ~e enaaed appgcadon; hhat ~as read the foregoing infomation sheet and knows the contents thereof' ~d ~at ~e same is tree to ~.o~k,~.~owledge except as to ~e matters herein stated to be alleged upon information and belief. and as to ~ose matters~elieves it to be ~e. (S(G~URE Of OFFICER)