Grantee Information Form
To ensure a smooth grant disbursement, please complete this encrypted form with your contact information, legal eligibility (including uploading IRS letter and W9), fiscal sponsor (if applicable), and banking details.
Primary Contact
Please enter the contact information for the primary point of contact on the grant project.
Contact Name
*
First Name
Last Name
Title
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is this person an authorized signatory for the organization?
*
Yes
No
Signatory
Please enter the contact information for the organization's authorized signatory.
Signatory Name
First Name
Last Name
Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Information
Legal Name
*
Please share the name the organization is legally registered under.
Public Name
If the organization goes by another name (e.g. an acronym, abbreviated name, etc.), enter that here.
Headquarters Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Board Chair
*
First Name
Last Name
Website
*
Is the grantee fiscally sponsored?
*
No
Yes
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Next
Legal Information
Tax status
C3
C4
Other
EIN
IRS determination letter
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Signed W9 form
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Fiscal Sponsor Information
Please complete this section with information about your fiscal sponsor.
Organization Name
Contact Name
First Name
Last Name
Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Headquarters Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Tax status
C3
C4
Other
EIN
Tax ID number
IRS determination letter
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Payment Authorization
Note: Only grantees who have been instructed to share this information are required to — please skip these questions unless you have been specifically asked to complete them!
Signed W9 form
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Bank Name
Accountholder Name
Bank Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Routing Number
Account Number
Submit
Should be Empty: