FLINT ENERGIES FOUNDATION GRANT APPLICATION

1.Please type application, if possible.

2.Attach a copy of your organization's most recent financial statement.

3.Attach a copy of your Internal Revenue Service letter or form showing 501(c) tax status; attach a copy of your Employer Identification Number if your organization is a school or government entity.

4.If you are requesting funds to buy a specific item, please include a cost estimate in addition to a detailed description of the item.

5.Funds will not be granted for general operating expenses or utilities.

Please contact Heather Nipper with any questions regarding applying for a grant.

Flint Energies Foundation, Inc.

Attn: Heather Nipper

(478) 847-5112

P. O. Box 308 Reynolds, GA 31076-0308

Additional pages or documentation can be attached to this application. After the application has been received and reviewed by Flint Energies Foundation, you will be contacted to schedule a date to appear before the foundation to make a brief five-minute presentation.

NOTE: If you have received a previous grant, your current request will not be considered until the 2 year lapse.

Organization

Organization Representative

Address

E-mail Address

example@example.com

Telephone Number

Fax Number

Website

Is your organization exempt from paying income tax?

YesNo

Tax EIN/ID

List the counties that your organization serves. Where possible, provide the number of individuals, families or groups that it served last year in the following counties: Bibb, Chattahoochee, Crawford, Dooly, Harris, Houston, Macon, Marion, Monroe, Muscogee, Peach, Schley, Sumter, Talbot, Taylor, Twiggs, or Upson.

Does the organization serve needs outside the counties mentioned above? If yes, provide information on the number served and locations Yes No

YesNo

If yes, provide information on the number served and locations.

State the specific purpose of your organization’s/agency’s request, including the requested amount and specific details on how funds will be used. Include cost estimates for contract work or equipment purchases.

Please enter the total amount of funds requested here: ($ ).

List other sources of funding that you have secured to meet the above request.

How do you measure the effectiveness of your programs?

Has this organization ever received funding from the Flint Energies Foundation? If yes, please provide an itemized statement of how those funds were used and attach it to this application. Yes No

YesNo

Reference Name, Phone Number, & Email

This information is for the purpose of obtaining funds from the Flint Energies Foundation, Inc. on behalf of the undersigned. Each undersigned understands that information provided herein is used in deciding to grant funds, and each undersigned represents and warrants that information provided is true and complete and that the Flint Energies Foundation, Inc. may consider these statements as continuing to be true and correct until a written notice of change is provided. The Flint Energies Foundation, Inc. is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. The Flint Energies Foundation, Inc. Board of Directors makes donations from funds collected through the Flint Energies Operation Round Up program. These funds are voluntary contributions from participating Flint Energies members.

Printed Name of Representative

Date

Signature of Representative

Please attach requested documents here.