Grant Application

1. Name of entity requesting funds.*

2. Address of entity requesting funds.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

3. Phone number of entity requesting funds.*

Please enter a valid phone number.

4. Email address if entity requesting funds.*

example@example.com

5. Describe the entity (legal composition, directors and staff, purpose, history).*

6. Amount of money requested.*

7. Provide a detailed explanation of how the funds will be used. You may attach supporting information or documentation that may be helpful to the directors as they consider this request.*

Upload supporting documentation here:

8. How will the Jefferson area benefit if your organization is awarded a grant?*

9. How many individuals do you estimate will benefit from your project on an annual basis?*

10. Describe the sources of other funds available, or being sought, to complete this project.

11. Please include financial statements for the last two year and year-to-date statements for the current year. These statements should consist of balance sheets for each of the three periods and operating statements showing actual results against budget for each period. Also show your sources of revenue.

Person representing applicant.*

Signature*

Title*

Signature of supervisor, if appropriate

Title of supervisor

The deadlines for submission of applications are April I and October 1. Foundation meetings to consider grant requests are held in June and December.

Applications may be mailed to:

Jefferson Community Foundation, P.O. Box 81, Jefferson, WI 53549