Application for Grant of Funds
(  P l e a s e  T y p e ) _________________________________________________________________________

Date:____________________

Telephone:____________________

Amount Requested:____________________

_________________________________________________________________________ Name and Address of Fiscal Agent , if different:

_________________________________________________________________________ Specific purpose for which grant is to be used:

_________________________________________________________________________

Period of time in which it is to be used: _________________________________________ Anticipated benefits

_________________________________________________________________________ How does this project/equipment fit in with the objectives of the organization (s) as a whole?

_________________________________________________________________________ What evidence is there of community support for this or similar projects, if applicable?

_________________________________________________________________________  

What are your organization's specific plans for the future funding of this project, if applicable?

_________________________________________________________________________

CHECKLIST OF REQUIRED ATTACHMENTS
(Include these Required Attachments with the Application Form:)

1. Letters of Determination from the IRS certifying tax-exempt status under Section 501 (c) (3) of the IRS Regulations for each participating organization.

2. Most recent Form 990 for each participating organization.  If any agency is not required to file a 990 Form, please explain and document.

3. Mission Statement from your organization and from each of the collaboration agencies, if a collaborative effort.

4. Completed Proposal Budget for Project.

5. Financial statements and/or audited report.

6. A list of your organization's current Board of Directors or from each organization, if a collaborative effort.

Please attach above items to this application. _________________________________________________________________________ INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED _________________________________________________________

__________________________________ (Type or print name)

_______________________________
(Type or print title)

 _________________________________________________________________________ Attach extra pages if space is too limited on this form.
NOTE:  Application deadlines: For June 1 distribution, completed application must be submitted by or postmarked by April 1;  For December 1 distribution, completed application must be submitted by or  postmarked by October 1.  Submit original application with attachments.
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