Flint Foundation Application

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 24 months.
Organization:*
Organization Representative:*
Address:*
Telephone Number: (Direct Line to Applicant preferred for scheduling purposes)*
E-mail Address:*
example@example.com
Fax Number:
Website:
Is your organization exempt from paying income tax?*

YesNo
Tax 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.*

YesNo

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 your grant request:*
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.*

YesNo

Please list three references and their contact information.*

Rows	Reference Name	Phone Number	Email
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2
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File Upload

Please upload any necessary files required as indicated in the above.
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Printed Name of Representative*

First NameLast Name
Signature of Representative*
Date*

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FLINT ENERGIES FOUNDATIONGRANT APPLICATION