COUNTERTERRORISM COMPLIANCE FORM
COUNTERTERRORISM COMPLIANCE FORM
In compliance with the spirit and intent of the USA PATRIOT Act and other counterterrorism laws, the United Way of the River Cities, Inc. requires that each funded agency (“Organization”) certify that it is in compliance with the United Way of the River Cities, Inc. and the United Way Worldwide’s (“UWW”) compliance program.
Organization Address *
Organization Address
City
State/Province
Zip/Postal
This Organization is not on any federal terrorism “watch lists,” including the list in Executive Order 13224, the master list of specially designated nationals and blocked persons maintained by the Treasury Department, and the list of Foreign Terrorist Organizations maintained by the State Department. *
This Organization does not, will not and has not knowingly provided financial, technical, in- kind or other material support of resources* to any individual or entity that is a terrorist or terrorist organization, or that supports of funds terrorism. *
This organization does not, will not had has not knowingly provided or collected funds or provided material support or resources with the intention that such funds or material support or resources be used to carry out acts of terrorism. *
This organization does not, will not had has not knowingly provided or collected funds or provided material support or resources with the intention that such funds or material support or resources be used to carry out acts of terrorism. *
This Organization does not re-grant to organizations, individuals, programs and/or projects outside of the United States of America with out compliance with IRS guidelines. *
This Organization takes reasonable, affirmative steps to ensure that any funds or resources distributed or processed do not fund terrorism or terrorist organizations. *
This Organization takes reasonable steps to certify against fraud with respect to the provision of financial, technical, in-kind or other material support or resources to terrorists and terrorist organizations. *
*In this form, “material support and resources” means currency or monetary instruments or financial securities, financial services, lodging, training, expert advise or assistance, safehouses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine or religious materials.
“I hereby certify on behalf of the Organization listed above that the foregoing is true and that all United Way funds and donation will be used in compliance with all applicable counterterrorism financing and asset control laws, statutes and executive orders.”