- 1 - GRANT REQUEST $:

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1 I. APPLICAT ORGAIZATIO PROFILE ame: Address: BOARD OF DIRECTORS (TRUSTEES): President/Chair: VP/Chair: Treasurer: Phone: ( ) - - Fax: ( ) - - Contact Person: Organization's Legal Status: (Trust, on-profit Corp. or Unincorporated Association ) ear Founded: 501 C (3): IRS Exemption Letter Date: Federal EI: H Dir. Of Charitable Trust Registration) #: (See RSA 7: b) Secretary: BOARD MEMBERS: Tax Return Form 990 Filed w/irs: (Attach OE Copy) 8. Annual Report (HCT 2A) or IRS Form 990 filed with H Director of 9. Charitable Trusts. If yes, attach OE copy. Conflict of Interest Policy Adoption Date: (Attach additional sheet if needed) II. SERVICE PROFILE # of registered members: # Staff: (Full time) (Part Time) # of people served in past 12 months: Compensation of 5 highest paid employees & position: Area of Service: (Geographic) 1) $ ational Affiliations: 2) $ 1. 3) $ 2. 4) $ 3. 5) $ 4. Description of services provided: (Please be concise) GRAT REQUEST $:

2 III. GRAT REQUEST Please provide a concise but detailed description of the project to be funded by this grant (Section III A-E should accurately show how the grant will be invested, what goals will be accomplished and how the project will be sustained after the grant funds are expended). Each Trustee must receive a legible copy on or before the deadlines of April 15 or October 15. Application for $ (Please specify amount) III A. Project Description: Please describe the specific project for which these funds are requested. Attach a proposed budget for this project showing how the grant will be spent; include a list of the project s expenses and revenues. III B. Project Goals & Objectives: Please list the specific goals and objectives by which the success of this project may be measured after its completion GRAT REQUEST $:

3 III C. Please provide a written analysis of the sustainability of this project once the grant funds have been expended. Has the Board analyzed the project s long-term sustainability? If yes, when. III D. Project Commencement Date: Fundraising Commenced: Project Completion Date: % of Board Solicited: Total Project Budget: $ % of Membership Solicited: Funds Received to Date: $ Membership Contribution: $ Funds Pledged to Date: $ Board Contribution: $ Date of Board Resolution approving the Project: III E. Outstanding Foundation Requests: ETIT AMOUT REQUESTED AMOUT GRATED GRAT REQUEST $:

4 IV. FUDIG HISTOR Prior von Weber Requests: Date Amount Project: (Brief Description) Granted V. FIACIAL SUMMAR OF APPLICAT Last F Last Fiscal ear (F) Ended: Sources of Support Amount Percent Last F Expenditures: $ Government Grants: $ % Last F Total Income: $ Program Fees: $ % Operating Fund Balance at End of F $ Endowment Income: $ % Current F Operating Budget: $ Other Earned Income: $ % Endowment- Today s Value: $ Event Fundraising: $ % Debt: $ Membership: $ % Dues to ational: $ United Way: $ % Real Estate Owned: $ Contributions: Equipment Owned: $ - Business $ % - Individuals $ % TOTAL $ - Foundations $ % GRAT REQUEST $:

5 VI. CERTIFICATIO Are copies of audited financial statements routinely provided to your Board? Does the Board routinely receive photocopies of each endowment s bank and investment statements? Is your endowment spending in compliance with H RSA 292-B? I certify that we have provided precise information concerning how the requested funds will be expended. We understand and acknowledge that any grant must be used in accordance with the information and materials set forth in and accompanying this application. This organization is in compliance with the registration and reporting requirements of the H Director of Charitable Trusts, the IRS and the H Secretary State. This grant request along with the application guidelines in Section III has been reviewed. A copy of this application should be forwarded to both co-trustees. President/Chair (Signature) Print or Type ame Date Executive Director (Signature) Print or Type ame Date ou will be informed of the Trustees decisions within 90 days of the submission deadline GRAT REQUEST $: