APPLICATION FOR GRANT

(a) Applicant organization must be a non-profit tax-exempt organization pursuant to IRS section 501c.3.

(b) Applicant organization must meet the Circle’s mission.

Projects or programs that promote a particular religious or political ideology.

Endowment or capital projects and campaigns.

Dinner galas, advertising, and other special fundraising events.

General operating expenses of an organization.

Intermediary funding agencies.

(d) Exceptions may be made by the Board of Directors at its discretion.

Application for Grant

Name of Organization

Contact Person and Title

Organization Mailing Address (required)

City, State, and ZIP Code

Phone

Tax exempt status and incorporation date:

Grant amount requested

Percent of total project

Statement

1) Brief statement summarizing the mission, objectives, and history of the organization:

Purpose

2) Brief summary stating the purpose of the proposal, project, or program, including the target population and need it will help most:

Objectives

3) Objectives of the project/program, expected outcomes, and how the progress will be measured and evaluated:

Timeline

4) Project/program timeline and/or the time period the grant will cover:

Future Needs

5) If this is an ongoing project, how will it be financed in the future? If this is a one-time purchase, how will maintenance of the purchased items, if applicable, be funded?

Other Funding Sources

6) If the PBRGC is unable to grant your full request, will partial funding prevent completion of the project? What changes, if any, will be made to the project in the event of partial funding? Are there other potential sources of income?

Summary of how this project will be financed

How the project money will be spent. Please submit purchase estimates and/or project bids.

Source of funds

Your organization’s contributions

Public contributions or donations

Loans

Other Sources (please specify)

Poplar Bluff Regional Giving Circle

Total Budget of Project

In addition to completing the financial information requested, please e-mail your organization’s most recent completed financial statement and the current annual budget, which also reflects year-to-date income and expenses, to pbrgcircle@gmail.com if you are sending your application electronically. Otherwise, attach them with the hard copy of your application you turn in to a board member.

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