GRANT APPLICATION
Organization Information
Date of Application: __________________________________________
Legal Name of Organization Applying: _____________________________________________
(This should be the same as on the IRS determination letter and as supplied on the IRS form 990)
Year Founded: ____________________ Current Operating Budget: ______________________
Executive Director/Administrator:________________________________________________
Contact Person/Title: ________________________________________________________
Address: _________________________________________________________________
City: _____________________________ State: _____________________ Zip: _________
Phone Number: _____________ Fax Number: _______________ E-mail: _________________
Proposal Information
Project/Program: ___________________________________________________________
Purposes/Objectives of Grant: __________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Date(s) of the Project/Program: __________________________________________________
Amount Requested: $ ____________________ Total Project/Program Cost: $________________
Geographic Area Served: _____________________________ Population Served: ___________
Other Sources of Support (if applicable): ___________________________________________
Authorization
Board Chairperson: ____________________________________ Date: ________________
(Signature)
Full Name/Title of Above: _____________________________________________________
Executive Director/Administrator: __________________________________ Date: _________
(Signature)
Full Name/Title of Above: _____________________________________________________
I certify to the best of my knowledge that the tax-exempt status of the organization is still in effect.
CHECKLIST
AN APPLICATION WILL ONLY BE CONSIDERED IF ALL OF THE INFORMATION IS INCLUDED*
(Please refer to the APPLICATION PROCEDURES AND GUIDELINES for further explanation.)
-------- A Completed and Signed Grant Application Form
-------- A List of the Board of Directors/Trustees/Officers/Administration (as applicable)
-------- The Most Recent Financial Statements (monthly or quarterly)
-------- The Latest Year-End Financial Statements (including Income/Balance sheets)
-------- The Current Year’s Budget (if available)
-------- The Current IRS Determination Letter
*Failure to include or submit all documents on or before November 30 will result in the application not being processed for this year's grant distribution.
The Annual Meeting is held in March.
You will be notified (through the mail) by March 31 of the decision made by the Board of Trustees.
(Please do not contact trustees.)
Thank you.
Name: ___________________________________________ Date: ___________________
PLEASE INCLUDE THIS CHECKLIST WITH YOUR APPLICATION MATERIAL.