Select One  501(c)(3) 
* Organizations with current tax-exempt status under Section 501c (3) of the Internal Revenue Service
Code and that are also public charities under section 509(a) (1) or 509(a) (2). Organizations must be
listed in the most current IRS 50 State Master File at the time of Application.
OR
 Public School 
 Federal, State or Local Government Agency 
Faith-Based Organization 
* Any grant of funds to a governmental entity would be conditioned upon the funds being used for public
purposes within the meaning of Scetion 501(c) (3) of the Internal Revenue Code
** Faith Based Organizations: funding purposes must address and benefit the needs of the commmunity at large
Federal 501(c)(3),(4),(6), or 19 Tax ID#
Organization Name
Address
City
State
Zip
Contact Name
Contact Phone
Specifically, how will funds from this grant be utilized in your local community?
What service(s) does you organization provide to the community?
Amount Requested
A. $
B. $
C. $
D. $
Promotional
Artwork Needed?
 Yes 
 No 
Height
Width
Date Due
Contact Email
Signed
Printed
Date
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