GRANT APPLICATION

(Please print/type)

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.


If you have any questions or need any additional information, please contact the

A. J. and Sigismunda Palumbo Charitable Trust office at (724) 778-9984.