PATRIOT ACT COMPLIANCE FORM
Anti-Terrorism Compliance and Charitable Status
In compliance with the USA Patriot Act and other counterterrorism laws, the United Way
of Escambia County requires that each agency certify the following:
“I hereby certify on behalf of
that all United Way funds and donations will be used in compliance with
all applicable anti-terrorist financing and asset control laws, statutes, and
executive orders.”
Additionally, I hereby certify that the above named organization is eligible to receive
charitable contributions as defined under section 170(c) of the Internal Revenue Code,
and that all contributions received from the United Way of Escambia County will be used
for exclusively charitable purposes.
Print name: ___________________________
Title: _________________________
Signature: ____________________________
Date: _________________________
Please return this signed agreement to the attention of Magi Thomley Williams, United
Way of Escambia County, 1301 W. Government Street, Pensacola, Fl. 32502.
Fax: 850-444-7117
Email: magi@unitedwayescambia.org