Emergency Assistance Application Form

Grant Information
What is the mission of your organization?*
When was the organization established?*
What geographic area does your organization serve?*
Are you a 501(c)(3) organization? If so, please attach a copy of your IRS 501(c)(3) recognition letter.*

YesNo
IRS 501(c)(3) recognition letter

Examples include eviction notice, medical bill, insurance report, or form and/or disaster report. File types accepted are pdf, jpg, png. Max file size of 10 MB.
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List your major donors during the last fiscal year, not including in-kind donations:*
Amount of grant request?*
Title of grant.*
Describe your grant.*
Provide a detailed description of the specific need/problem being addressed through the grant.*
Describe the demographics of the population you plan to serve and how your efforts will benefit them and the community.*
List the specific objectives of this grant. (Be specific about the number of people impacted.)*
Please state how the Foundation’s support would be acknowledged if a grant were made.*
Provide as much detail as needed regarding the proposed use of funds.*
Indicate the percent of your organization expenses that go to the following. (must equal 100%):
Administration:*
Programs:*
Fundraising:*

Signature
Agreement and Signature By submitting this application, I affirm that the facts set forth in it are true and complete.
Signature*

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Contact Information