Equity Fund Statement of Interest

Equity Fund Statement of Interest
Date

MonthDayYear
Date
Primary Contact Name

First NameLast Name
Email
example@example.com
Job Title
Phone Number
Format: (000) 000-0000.
Tax Exempt EIN
To be tax-exempt under section 501(c)(3) of the Internal Revenue Code, an organization must be organized and operated exclusively for exempt purposes set forth in section 501(c)(3), and none of its earnings may inure to any private shareholder or individual. In addition, it may not be an action organization, i.e., it may not attempt to influence legislation as a substantial part of its activities and it may not participate in any campaign activity for or against political candidates.
Agency Name
Equity Fund Program(s) Name:

0/10
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency Information
1. Agency Status
1a. If the agency is using a fiscal agent, please enter the name of the organization below:
2. Neighborhood(s) or zip code to be served with Equity Fund project:
3. Funds will be requested to implement resident-identified solutions for their neighborhood
4. Community to be served is 30% or greater low income according to census data (under $25,000 household income).
5. Residents to be targeted are majority persons of color.
6. Proposed activities will address the below priority area(s) of inequity. Please select all that apply.
7. Applicant will be able to report the results of United Way’s investment by Sept. 30, 2023
Should be Empty:

Agency Information