Text Box: PROSPECT GOSHEN ROTARY FOUNDATION FUNDING REQUEST Complete this form, with attachments as indicated.  Keep a copy for your records, and submit the original to the Foundation Secretary no later than February 1, May 1, August 1, or November 1, for review.  If approved, funds are distributed on April 1, July 1, October 1, and January 1.

Date of Application:

 

 

 

Sponsoring Member:

 

Amount Requested:

$

 

Prior Awards (Year and Amount)

 

 

Organization Information

Name:

Address:

City, State, Zip:

Executive Director:

Phone:

Email:

 

 

 

 

 

 

 

Contact

Name:

Business Address:

Phone:

Fax:

Email:

 

 

 

 

 

Tax Status:

Federal Tax ID:

Nonprofit?

Exempt Status?

Affiliated with other organizations?

 

 

 

 

 

Funding Information:

FY

Annual Operating Budget:

Current Year

Previous Year:

 

 

 

 

Other Funding Sources:

United Way

Federal Government

State Government

Local Government

Other

 

 

 

 

 

Organization Personnel:

Number of Full Time

Number of Part-Time

Number of Volunteers

Number of Directors on Board

 

 

 

 

Project Description

Nature, scope, current status

(3000 character limit or attach separate sheet)

 

 

 

 

 

 

 

What need is addressed by this project?

 

 

Who will benefit?

 

 

 

Are other organizations involved?

If yes, list.

Y  N

 

 

 

 

Start Date of Project

End Date of Project

 

Project Funding

Total project cost/budget

Percent of current year budget

$

%

 

Other funding sources: (list name and amount from each)

 

 

 

 

 

 

 

 

 

 

 

 

Certification:

 

Signature of Officer:___________________________________________  Date:_____________

 

This signature certifies that the fundseeking organization retains its public charitable status stated above, and further certifies that this status is not in danger of being revoked.  In addition, this signature affirms that the funding organization (Rotary Foundation of Prospect/Goshen) has not received any goods or services in conjunction with this request, and that all information is correct to the best knowledge of the signer.

 

Text Box: Complete this form, with attachments as indicated.  Keep a copy for your records, and submit the original to the Foundation Secretary no later than February 1, May 1, August 1, or November 1, for review.  If approved, funds are distributed on April 1, July 1, October 1, and January 1.

 

Required Attachments

·         Copy of exemption letter (Proof of 501(c)(3)/509(a) status)

·         IRS form 990 for the most recent fiscal year

·         If the grant request is for a specific project, provide a detailed budget for the project, including expenses and income

·         Income statements/balance sheets for the two most recent fiscal years (audited, preferably)

·         List of Board members, titles, affiliations, phone numbers, and compensation (if applicable

 

Disposition

 

Date of Disposition:

Approved:

Rejected:

Board of Directors

 

Signature

Date Paid:

 

Check No.

Explanation: