Omega Life Membership Foundation, Inc. Grant Request Form
Date of Application
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Month
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Day
Year
Date
Organization Name
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Organization Contact Email
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Executive Summary
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Budget Narrative
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Legal Name: (Should be same as on IRS determination letter and as supplied on IRS Form 990.)
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Federal Tax ID Number
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Upload a copy of the organization’s IRS 501(c)3 Determination Letter including the Tax Identification Number or International Equivalent as a Registered Nonprofit
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Requesting Director/Chairman
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Contact person/title/phone number (if different from Director/ Chairman
First Name
Last Name
Address (principal/administrative office)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Program Name
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Dates of Project
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Amount Requested
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Total Project Cost
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Purpose of Grant
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Measurable anticipated outcome
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Submit
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