Grant Request - for 2009 funding (2 pages)

Please print, fill out in its entirety, and return to: P.O. Box 367 Spruce Pine, NC 28777.

NAME OF ORGANIZATION: _____________________________________

ADDRESS: ______________________________________________________

CONTACT PERSON: _____________________________________________

TELEPHONE: _________________________

EMAIL: _______________________________

501-C-3    yes    no    (circle one)    TAX EXEMPT#: ___________________

TOTAL GRANT FUNDS REQUESTED: __________________

Specifically describe the intended use of the requested funds (Use additional pages if necessary).
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       

Your total budget for the project/purchase detailed above: _______________________________
Project/Purchase start date: __________________________
Project/Purchase end date: ___________________________

U/W Approval

List other sources of income which are available to your agency for completion of this project.
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       
                                                                                                                                                                       

Please include the following information with this application:

1. A list of current Board members including their telephone numbers.
2. A financial statement or audit for the past fiscal year.
3. Any other pertinent information that you feel will help the United Way in making its decision related to your application.

THIS APPLICATION WILL NOT BE CONSIDERED FOR FUNDING UNLESS ALL OF THE INFORMATION REQUESTED IS INCLUDED.

THE APPLICATION IS DUE BACK IN OUR OFFICE NO LATER THAN DECEMBER 1, 2008 FOR CONSIDERATION FOR 2009 FUNDING.