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[[[["field13","equal_to","Yes"]],[["show_fields","field14"]],"and"],[[["field13","equal_to","No"]],[["show_fields","field15,field16,field17"]],"and"]]
1
Nameyour full name
Charity Name
City
State
Zip Code
Fed. Tax ID #
Exempt Under Sec. 501 (C) (3) of the IRS Code?
If Yes, Please attach IRS determination letter:upload
Upload
(If no, please read eligibility requirements and attach detailed explanation of eleigibility)
Detailed explanation of eligibility:
0 /
What is the purpose or mission statement of your organization?
0 /
Chairman of the Board:
Name
Phone
Addressyour full name
Executive Director:
Name
Phone
Addressyour full name
Treasurer:
Name
Phone
Addressyour full name
II. Grant Request Information
Amount of Request: $
Check One
In one sentance, please summarize how the funds request will be used:
0 /
Why do you think this use is needed?
0 /
Person responsible for project/proposal:
Phone:
Address:

We hereby apply for a grant in the amount listed above and certify that the information contained herein and in the attached materials is true and correct to the best of our knowledge.

(required)
Organization:
By (authorized office):
Title
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