SDSU Extension Charter Application
SDSU Extension CHARTER APPLICATION
for
4-H Clubs and Affiliate Organizations
Green 4-H Club
Requested Name of 4-HCAO: I Bleed
_____________
X 4-H Club or
_____
_____ 4-H Affiliate
____________________________
Lincoln County, SD
County / Unit / State ___________________________________
(circle one above)
(name of County/Unit/State)
John A. Clover
Official Contact Person’s Name: _______________________
Type of 4-H Unit
____
4-H Club
__________
__________
(i.e.: 4-H Club, 4-H Special Interest Group, County 4-H Leaders Council, etc.)
New 4-H club; To provide positive youth development opportunities to meet the needs of
Stated Purpose of Group:________________________________________________________
young people in a long-term, progressive series of educational experiences within a club setting.
_____________________________________________________________________________
The following checklist/documents must be submitted along with this request form to the
State 4-H Office to apply for a 4-H charter designating the unit as an official 4-H CAO.
Clubs
X
_____
An Official Club or Affiliate Name is Requested Above
X
_____
Five (5)or more members from at least three (3) families are members
Andy White
Samantha Green
_________________________
_________________________
Jenny Clover
James Clover
_________________________
_________________________
Jane Heart
______________________________
X
_____
One Registered Volunteer Form on File (or in progress)
John A. Clover
______________________________
X
_____
Copy of 4-H Club or 4-H Affiliate Constitution & Bylaws Included
X
_____
Copy of 4-HCAO Dissolution Statement Included
X
_____ Copy of IRS Form SS-4 (EIN app) if there is a Treasurer or EIN Nmbr
Affiliates
_____
_____
_____
_____
_____
EIN application can be done online or a blank form can be found at
https://sa1.www4.irs.gov/modiein/individual/index.jsp
PENDING
_________________________
(EIN Nuumber)
By signature of this charter application I hereby authorize the financial institution handling any bank accounts for
this club/affiliate organization to make records available to authorized representative(s) of the SDSU Extension
State 4-H Office.
______________________________
Signature of Official 4-HCAO Contact from Above
______________________________
Date
Released October 17, 2012