APPLICATION FOR COMMUNITY GRANTS Operational Year Application Deadline: Monday, March 4, Telephone Number: Address:

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1 Page 1 of 6 APPLICATION FOR COMMUNITY GRANTS Operational Year Application Deadline: Monday, March 4, 2019 Requesting Organization: Mailing Address: Point of Contact and title: Telephone Number: Address: IRS EIN: IRS Letter of Proof included: Y N If you do not have an EIN number, briefly explain why. This page to be completed by FPSC Community Grants Chairperson only Date Received Action Taken Amount Approved Check # Defense or any of its components and it has no governmental status

2 Page 2 of 6 Type of Request (Please check one) o Educational Institution o Non-profit Organization o Public organization or Group o Business (such as DAV) o Other (Please specify) Amount Requested (In U.S dollars): $ Please briefly explain how the requested funds will be used. Be as specific as possible and include a proposed itemized breakdown of how funds will be spent and the timeline for use of the funds. Elaborate on additional paper if necessary. Note: We are unable to provide funds for general requests such as operating costs We are much more likely to fund specific projects with a demonstrated need, such as curriculum materials for our adult education class. How did you hear about the Fort Polk Spouses Club Community Grants? (Circle) Friend Past Applicant Newsletter FPSC Website ACS Board Member Does your organization provide services for active duty, their families, Gold Star spouses/families, or retirees/veterans?

3 Page 3 of 6 If yes, what percent of your organization s clients are affiliated with the military: Check which population your organization serves: o Active Duty o Spouses o Children of active duty o Gold Star spouses/families How does your program benefit the Fort Polk community? Have you requested funds for this purpose from any other organizations? YES NO If yes, please list organization names and amounts requested. Have you previously received funds from the Fort Polk Spouses Club? (If known) YES NO If yes, please list amounts and years received as well as how these funds were used. Are you receiving appropriated funds? (Required for processing procedures) YES NO

4 Page 4 of 6 How has this organization raised funds previously and/or how are funds currently raised? What would you like for FPSC to know about your organization? If funds are granted, to whom should the check be made payable? Note: Checks cannot be made payable to individuals. If funds are granted, recipients must complete the FPSC audit sheet (to be mailed with the check and notification letter) stating how the FPSC grant funds were used and provide copies of itemized receipts. The audit form must be returned within 90 days of fund disbursement or no later than December 20, 2019, whichever is greater. Is your organization able to complete this process within the allotted time? If not, why? When would you be able to turn in your receipts and audit form?

5 Page 5 of 6 By initialing each statement below and signing this document, I affirm that the statements provided are strictly true in every respect, and I will comply with the initialed statements if my organization is granted requested funds. I understand that if my organization is granted funds, those funds are to be used for the purpose detailed in this application only. If funds cannot be used for the designated purpose, they will be returned to the Fort Polk Spouses Club through proper channels. If I have questions regarding this procedure, I am to contact the Community Grant Chair. I understand if a grant is awarded, I must complete the enclosed audit sheet stating how the FPSC grant funds were used and provide copies of itemized receipts. The audit form must be returned within 90 days of fund disbursement or no later than December 20, 2019, whichever is greater. I understand that the application deadline is March 4 th, 2019 and my application must be received or postmarked by that date. I further understand if my application is received after that date, it will not be considered. I understand that failure to comply with set terms may disqualify this organization from subsequent Fort Polk Spouses Club community grants consideration. Printed Name/Position Title Signature Date: Upon completion, mail signed application with all required attachments to: Fort Polk Spouses Club Community Grants Committee PO Box 3911 Fort Polk, LA ****If you have any questions about the application process or eligibility criteria, please contact the Community Grants Chair at fpsccommunitygrants@gmail.com. Subject: ATTN: Community Grants Eligibility or Application Process Candice Cartwright Fort Polk Spouses Club 2018/2019 Community Grants Chair

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