Community_Assistance_Grant_Application_2010-2011.318165245

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					                       Fort Leavenworth Spouses’ Club
                      Community Assistance Committee
                                  P.O. Box 3004
                            Ft Leavenworth, KS 66027
                                  (913)651-9454
                        ftleavenworthspousesclub.com

                  Community Assistance Grant Application 2010-2011


Name of Organization:_________________________________________________

Tax ID number, if applicable:____________________________________________

Name of Contact Person:_______________________________________________

Daytime Telephone: ____________________Evening:_______________________

Email:______________________________________________________________

Mailing Address:               ______________________________________________

                               ______________________________________________

                               ______________________________________________

Check shall be issued to:
                               ______________________________________________

Address to where check should be sent, if different from above:

                               ______________________________________________

                               ______________________________________________

Amount of Request: ____________________________________________________

Specific purpose of funds being requested, to include amount and purchase price of
materials, equipment, or services (e.g. replacement of old/broken chairs for youth activities, 15
chairs at cost of $20.00 each, flyer included from School Supplies Inc.):

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

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If you received funds from the FLSC Community Assistance Committee in the past,
please note the amount, how the funds were utilized and provide proper documentation
(e.g. receipts).     (FLSC Grants may not be requested for items/purposes that have been awarded
grants in previous years without providing documentation of on-going need. For example, if more new
chairs are needed for youth activities, provide receipts showing purchase of chairs from previous
request.)
______________________________________________________________________

______________________________________________________________________

______________________________________________________________________



Has your organization raised funds during the year?

       YES     ____ NO         ____

       If your organization raises funds during the year, please state the amount.
                     Amount:        _________________________________

                       Use:_________________________________________________

                       ____________________________________________________

                       ____________________________________________________

                       ____________________________________________________

Organization’s membership structure:

        Total number of members/people served:                         ____________

       Total number military/military family members served: ____________


Briefly indicate the purpose of your organization and its benefits to the community as
related to the requested funds. Please include how many individuals will directly benefit
from the requested funds.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________



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If there is any other information about your organization that the members of the FLSC
Community Assistance Committee should consider, please state here or attach a
separate sheet.

______________________________________________________________________


______________________________________________________________________

______________________________________________________________________



Will you authorize use of your organization’s name for public recognition of receiving the
grant? If yes, please sign here:

                                  __________________________________________

This Section to be completed by Official Fort Leavenworth activities and agencies
ONLY:
      Is this organization a government funded agency?
              YES: ____           NO: ____
      If YES, has this request been approved by the Garrison Commander?
              YES: ____           NO: ____
      Please provide letter of approval.

      Are you authorized Appropriated Funds for the purpose of this request?
              YES: ____            NO: ____
      Are you authorized Non-appropriated funds for the purpose of this request?
              YES: ____            NO: ____
      If the answer to either or both is YES, please explain why such funds are
      insufficient for this purpose:

      ___________________________________________________________

      _______________________________________________________________

      _______________________________________________________________

      _______________________________________________________________




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A. The FLSC requests that you answer all questions. Applicants may handwrite or type
   requested information on this form, or may copy this form into a Microsoft Word
   document to complete their application provided that the content of the document is
   not changed in any way.

B. All requests must be emailed to flsccommunityassistance@hotmail.com and
   received by February 16, 2011.



The application will not be considered for a grant if above mentioned A. and B. as
also required additional documentation (where applicable, i.e. garrison
commanders’ letter) is not provided until the end of the aforementioned deadline.

All checks awarded by the 2010-2011 FLSC Board must be cashed by May 30, 2011.


For further information please contact Cathy Gilewitch at 913-728-2423 or
flsccommunityassistance@hotmail.com.




Date (MM/DD/YYYY)________________Signature___________________________


(For FLSC use, please leave blank)

Date Received:      ______________________________

Date Postmarked: ______________________________




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