Rochester Common application form

2. Information Sheet

 

GRANT APPLICATION TO (name of funder):

 

Organization Information

 

Name & address of applicant organization:

 

 

 

Is the name at the left the same as it appears on the IRS 501(c)(3) Letter of Determination?   __yes   __no

If not, explain:

 

Telephone Number:

 

Fax Number:

 

E-mail:

 

For current fiscal year:

    Organization’s total budgeted revenue:

    Organization’s total budgeted expenses:

 

Fiscal year: __________ to __________

 

Revenue Sources:

Chief Executive Name and Title:

 

 

9-digit Federal Employer ID #:

 

Year organization incorporated:

___ % government (city,

county, state,

federal)

___ % United Way

___ % membership dues

 

___ % fees

___ % grants

___ % investment income

___ % fund raising (e.g.

            events, gifts, bequests, etc.)

 

Information for This Request

 

Name of this program or project:

 

 

Program/project contact person:

List other potential and actual sources of support - put an “*” by those committed, noting any matching fund requirements.

Amount          Funder

   Name:

 

   Phone #:

 

Total cost of this effort:

 

Amount requested from this funder:

 

 

Type:

 

__Capital

__ Construction

__ Renovation

__ Equipment

__Endowment

__Program/Project

__General Support

__Other (describe)

 

 

 

 

List major funders of program/project for past two years if applicable:

Amount          Funder

 

Date funds needed by:

 

 

Date by which funds will be spent: