| Name of Organization: |
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| Email Address: |
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| Date Prepared: |
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| Principal Office - Address: |
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| City: |
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| State: |
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| Zip: |
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| Telephone: |
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| Incorporated as a Non-Profit (Y/N)?: |
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| Date and State of Incorporation: |
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| Has your organization qualified as a non-profit, tax deductible entity under the U.S. internal revenue code 501(c)(3)?: |
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| If not, enter application date: |
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| Request - Total Amount Requested: |
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| Is this amount for one Fiscal Year (Y/N)?: |
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| If no, for what period?: |
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| Use of funds: Please outline proposed project or program, identifying both your target population and your planned method of improving that group's quality of life. Be specific. Please attach a detailed budget for the use of the requested funds.: |
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| Purpose and Program - State your organization's objectives: |
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| Briefly summarize your organization's current efforts toward achieving those objectives: |
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| What geographic area do you serve: |
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| Describe your agency's efforts to collaborate with other organizations whose services parallel, duplicate, or aid your work: |
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| Name and title of paid staff head: |
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| Date of appointment: |
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| Prior affiliation: |
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| FINANCES - Please complete with respect to applicant organization only. DO NOT include parent company financial information (mm/dd to mm/dd): |
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| Revenue received last fiscal year excluding capital campaign funds: |
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| Total government revenue received last fiscal year: |
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| Total approved budget for current fiscal year: |
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| Salary range, including deferred compensation, for all of your organization's paid employees (From $XX.XX To $XX.XX): |
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| List the methods of fund raising, used or planned (direct mail, membership solicitation, corporation/foundation solicitation, etc.), that generate your organization's revenue: |
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| List any outside fund raisers and your payment rate to them: |
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| Accounts are audited by (i.e., Certified Public Accountant, An Auditing Committee, etc.): |
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| Frequency of audits: |
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| ADDITIONAL INFORMATION - Please mail hard copies of the following upon submitting your application (1) Copy of U.S. Treasury ruling granting your organization status as a non-profit, tax deductible organization under section 501(c)(3); (2) Complete audit for the previous fiscal year; (3) If combined cost of administration, public relations and fund raising exceeds 20% of total expenditures for the previous fiscal year, please enclose a statement explaining your high administrative expenses; (4) List of corporate donors exceeding $200; and (5) Project or program budget. These items will be sent by: |
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| By inputting my name, title and the date in the adjacent text box, I certify that the aforementioned and enclosed information is complete and accurate: |
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