Sample 501C3 Application for a Church by nnh71223


Sample 501C3 Application for a Church document sample

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									COVER SHEET for
Recession Response Fund
1. Organization Contact Information

Legal Name of Organization:

Other Names or Acronyms of Organization:

Mailing Address:

City:                                             State:                    Zip:

Web Address:

Organization Phone:                               Fax:

Executive Director:

Director Phone:                                   Email:

Project Coordinator Name/Title:

Coordinator Phone:                                Email:

2. Project Information

Project Title:

Amount Requested: $                               Total Project Budget: $

County/Area to be served by the project:

3. Organization Information

Applicant’s Tax-exempt Status (Please check one):

   501(c)(3) Organization.
    Employee Identification Number (EIN): __ __ - __ __ __ __ __ __ __
   Public Agency
   Church

Organization’s Total Annual Operating expenses: $

For the Fiscal Year Starting:                     Ending:

Date of most recent Audit:

If not yet available when expected:

Staffing: Number of paid full time equivalent staff _____
          Number of active volunteers _____

4. Board Information
How many Board Members are serving on the board at the time of application? __

How many Board members have made a personal financial contribution in the past 12 months? _

How many Board Meetings have occurred with a quorum of members in the past 12 months? _

5. Board Chair/President’s Statement of Compliance:
The Community Foundation derives its grant funds from multiple sources. By signing this form, I hereby
give permission for this proposal to be shared with Foundation donors and other appropriate parties.

By my signature I certify that the information provided in this application is correct and that the governing
board of the organization has been notified of this proposed project.

Through its competitive grants process, The Community Foundation of Western North Carolina only
supports organizations that comply with all applicable federal, state, and local regulations, including but
not limited to discrimination against a person or group on the basis of: age, race, national origin, ethnicity,
gender, disability, or religious belief. By my signature, I affirm that our organization is in compliance.

________________________                  _____________________________          ___________
Printed Name                              Signature                              Date
President of Nonprofit Board
or Authorized Official of Public Agency

    Attachments: (Please include one copy of each item in the order listed. Please also provide all
    requested documents in a vertical orientation to facilitate reviewing on line.)

   RRF Cover Sheet – (This form signed by the Board Chair/President not the Executive Director)

   Emergency Assistance and Operating Grant Application Form including Narrative Questions (Limit to
    2 page maximum, 12 point font minimum and 1 inch margins, please)

   Board List – Two page maximum, showing their primary professional or community affiliation, position
    on the board and terms of service. (See sample on website)

   Organization Operating Budget - Attach your organization’s operating budget showing line item
    income and expenses for your organization’s current fiscal year (two page maximum). (Fiscal agents
    should provide a program budget for the project they are submitting.)

   Year to Date Financials –Submit your organization’s year-to date budget versus actual as of June 30,
    2009 and most recent Balance Sheet.

   If your organization’s budget is between $25,000 and $150,000, please submit your current 990 or
    note if CFWNC already has a current copy.

   If your budget is greater than $150,000, please submit your most recent audit or note if the CFWNC
    has a current copy.

   Note – Public Agencies (Municipalities, etc.) do not need to provide the last three items.

Submit with original signature to:
The Community Foundation of Western North Carolina
Mailing Address: Post Office Box 1888, Asheville, NC 28802
Location: Suite 1600, the BB&T Building, One West Pack Square


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