Grant Application Form for Organizations

Application

Date of application *

Full name of organization *

Address *

Phone *

Fax

Email *

Tax Identification Number

Does your organization enjoy tax-exempt (501(c)3) and/or 509(a) status? *

—Please choose an option—yesno

Mission Statement *

How long has your organization been in existence? *

Estimated number of individuals served by organization *

Is organization an educational institution or affiliated with one? *

—Please choose an option—yesno

If yes, please specify which

Please describe your organization in 500 words or less *

Current board of directors *

Organization's current annual budget ($) *

Please attach a copy of your organization current budget

Organization’s Annual Financial Statements: Attach copies for your two previous fiscal years.

Note: Financial Statements will only be required of finalists.

Project description and statement of need *

Estimated number of individuals served by project *

Anticipated starting date of project *

Anticipated ending date of project *

Total budget for project ($) *

Please attach a copy of the project's budget

Do you have other funding for this project? *

—Please choose an option—yesno

If yes, please list the source, the amount, and whether the funding has been received or is anticipated.

How will you determine / evaluate your project’s success? *

Additional information that you would like the Grant Committee to consider

Statement of Accountability

I (we) attest that the information given above is accurate and that if we are awarded this grant, we will strive to the utmost of our ability to achieve the goals we have set, within the timeframe we have outlined **

** Please note: Within one year following receipt of your grant, you will be required to submit a “Proof of Benefit” essay to the Foundation describing ways in which this financial assistance made a difference to your success.