FLINT ENERGIES FOUNDATIONGRANT APPLICATION
1. Please type application, if possible.
2. Attach a copy of your 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.
Flint Energies Foundation, Inc.
Attn: Heather Nipper
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 lapse of 36 months.
Organization:
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Organization Representative:
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Address:
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Telephone Number:
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E-mail Address:
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example@example.com
Fax Number:
Website:
Is your organization exempt from paying income tax?
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Yes
No
Tax ID #:
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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.
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Does the organization serve needs outside the counties mentioned above? If yes, provide information on the number served and locations.
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Yes
No
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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.
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Please enter the total amount of your grant request:
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List other sources of funding that you have secured to meet the above request.
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How do you measure the effectiveness of your programs?
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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.
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Yes
No
Please list three references and their contact information.
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Reference Name
Phone Number
Email
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2
3
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Printed Name of Representative
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First Name
Last Name
Signature of Representative
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Date
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Day
Year
Date
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