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300 Grant Application
- 1. The 300 Grant Application Individual and Partnering Organization Grants up to $5,000 SUBMITTAL CHECKLIST Completed Application (3 pages, including this cover), signed by the CEO of the Applicant Organization Program or project budget (1 page) IRS Form 501(c)(3) Certification of Tax Exempt Status Current Board List with employer (if applicable), address and phone Annual Financial Statement (audited if available) for most recently completed year Provide an explanation (in an Attachment) if a permit or other regulatory approval is needed to conduct this program, project or event. APPLICANT ORGANIZATION INFORMATION Applicant Organization: Executive Director or Board Chair: Project Contact (if different from above): Organization address: City: State: North Carolina ZIP: Telephone: Fax: Email: PROJECT OVERVIEW Project Title: Grant Request: Total Project Budget: Total Organizational Budget: Have you previously received a 300 Fund grant? If so, year(s) and project name APPROVAL OF CHIEF EXECUTIVE OFFICER I have reviewed and approved submission of this grant request. I certify that the Applicant Organization does not discriminate on the basis of race, color, age, sex, national origin, sexual orientation, or gender identity. I also certify the organization has received no notice from the Internal Revenue Service of any proposal, threat or suggestion to revoke or modify our 501(c)(3) determination. I certify and attest that the Applicant Organization meets all eligibility requirements and agree to all terms and conditions applicable to grant funds. I attest that the organizations membership and/or service population are contained within the 17 counties of Western North Carolina and agree and certify that grant funds will be used solely within this region. I agree the Fund may, in its sole discretion, make public (a) the fact that this organization is a grant recipient; (b) the activities or purposes for which the grant is made; and, (c) the services or benefits for which the funds will be used. I agree and certify that grant funds will be used solely and exclusively for the purpose(s) and time period(s) stated in the grant application and that any other uses or time periods must be pre-approved in writing by the Funds Board of Advisors. Chief Executive Officer Signature Printed Name Date
- 2. Please answer the following questions, entering the response after each question using as much space as needed without exceeding four pages for all responses. Type size must be 10 pt or larger with no changes to margins. 1. What is the mission of your organization? 2. What services and/or programs do you currently provide? 3. What unmet need have you identified in the community? 4. Describe your expected use(s) for the requested grant funds. 5. What are the expected outcomes for your programs and/or services and how are the outcomes measured? 6. How do your programs and/or services reach and/or benefit members of the 17 counties of Western North Carolina? Include the population and number served, as well as other pertinent demographics. 7. If the full amount of the requested grant cannot be awarded, how will your programs and/or services be funded? 8. Please attach a program or project budget, including anticipated sources of income and detailed expenses. Also please indicate which expenses will be covered by a grant from the Fund, if awarded. 9. Does your organization have a nondiscrimination policy that includes sexual orientation? If yes, please attach a copy of your policy.