Grant Request Form For the fastest response, please complete this online form.If you prefer printing and mailing your application, download the PDF version of the form > 12345 Upload the following files:Verification of 501(c)(3) tax-exempt status.IRS 501(c)(3) letters*The advance or definitive IRS determination letters indicating 501(c) (3) tax-exempt status. Maximum file size allowed: 64MB Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. Most recent IRS Form 990*Copies of the most recent IRS 990. Maximum file size allowed: 64MB Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. Financial Statements*Upload copies of the financial statements for the most recent year. Maximum file size allowed: 64MB Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB. Legal Name of Organization*Year Founded*Current Annual Operating Budget*Executive Director* First Last Email* Contact Person/Title (if different from Executive Director)Address (principal/administrative office)* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*FaxWebsite Project Name*Purpose*Amount Requested*Total Project Cost*Project Goals*Beginning Date of Project/Campaign* MM slash DD slash YYYY End Date of Project/Campaign* MM slash DD slash YYYY Geographic Area to be Served*I certify, to the best of my knowledge, that: 1. The tax-exempt status of this Organization is still in effect, 2. This Organization does not support or engage in any terrorist activity, and 3. If a grant is awarded to this Organization, the proceeds of that grant will not be distributed to or used to benefit any organization or individual supporting or engaged in terrorism or used for any other unlawful purpose. ESIGN DisclosureSection 101 of the ESIGN Act, sub-section (b), preserves the rights of individuals to NOT USE electronic signatures. Here the law provides that individuals reserve the right to use a paper signature. Sub-section (c) is in direct support of (b) by requiring a “Consumer Disclosure” that the signatory has consented to use an electronic format.Signature: President, Board of Directors* I consent to using an eSignature I do not consent to an eSignature, I prefer a paper signature Signature: Executive Director* I consent to using an eSignature I do not consent to an eSignature, I prefer a paper signature Problem and Need*Identify the problem to be addressed and the needs to be met by the project. Provide supporting data.Program / Project Design*Describe your program objectives, activities, strategies, staffing, partners, timelines and explain how the design will enable you to address the problem or need. Identify the project as a new or continuing program.Sustainability*Specify your plans for financing the project at the termination of the grant. List other financing sources or strategies that you are developing.Evaluation Interim and final evaluation and expenditure reports will be required for every grant awarded. It is important to design your evaluation process at the outset and begin to collect data from the beginning of the project, program or campaign.Outcomes*Describe the proposed program or project outcomes, with reference to long-range plans of the organization. What outcomes do you want to produce by the end of the first year, second year, etc.? If your program is continuing, what intended outcomes have been achieved thus far?Measurement*Outline your plan to document progress and results. How will you measure expected outcomes and the effectiveness of your activities? What will be your criteria for success? What tools will you use to evaluate your program and organization (records, surveys, interviews, pre-and post-tests, community feedback, etc.)? Organizational StructureOfficers and Directors*List of officers and directors, including occupations, places of employment, etc.Key Staff*List of key staff members involved in the project. Financial InformationProgram / Project Budget*Current Operating Budget*Organization's current operating budget. Itemize all expenses and revenues.An accurate, detailed budget for the proposed project is required.Budget HeadingSpecify the budget periodBudget Period Start Date* MM slash DD slash YYYY Budget Period End Date* MM slash DD slash YYYY Request Amount*Specify the requested amount for the project.Total Cost*Specify the total cost of the project.Revenue*If the requested amount is different from the total cost of the project or campaign, itemize all confirmed and anticipated sources of revenue, and provide a revenue total. Also, indicate the amount of funds, if any, for this project that will be drawn down from your operating budget and/or reserve fund or endowment.Expenses*Itemize your expenses and provide an expense total. Include any additional items relevant to your particular program, project or campaign.Narrative*This section should include: - A list of assumptions on which the budget was based. - An explanation of any unusual budget items. - In-kind expenses and donations or matching funds should also be described. - If your organization has affiliates and/or subsidiaries, please explain.