Date:

Legal Name of Organization:

Address:

City, State, Zip:

Contact Person and Title:

E-Mail:

 

Phone#:

Fax#:

IRS 501(c)(3) nonprofit?    Yes No
    If YES, attach IRS letter confirming your 501(c)(3) status.

Amount Requested:  $

Type of Request:

Operating Specific Project Capital Other

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Organization's Mission:

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Summary of Proposal:

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List the proposal's target population, constituents and geographic communities:

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How will this benefit under served populations specifically those of low to moderate income?

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Please include details of what percentage served qualify as low to moderate income. (Please provide supporting documentation)

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Total Number of Paid Staff:   Full-Time:  Part-Time: 

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Please include the following documentation with your application:

1. Organization Profile:
   1. Brief summary of organization's history, goals and key achievements
   2. Overview of organizational structure and size, such as board, staff and volunteers
   3. Description of organization's membership, including total number and geographical area encompassed
2. IRS letter confirming tax-exempt status of 501(c)(3)
3. Current Board roster with relevant background data, affiliations and town of residence
4. Financial Information:
   1. Total board approved organizational budget for the fiscal year(s)
   2. If seeking project or capital support, include project or capital budget for fiscal year(s)
   3. Most recent independent audit, if required by law; Year-to-date financial statement for your current fiscal year

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Have you applied to other resources for this funding?     Yes No

If so, please list those:

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