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| Marian
Cooper Community Foundation |
| Grant
Application |
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|
Organization Information |
| Applicant
Organization: |
| Mailing Address:
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| City:
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State:
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Zip: |
| Telephone:
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Fax: |
Years in existence:
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| Website: |
Fed ID: |
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| Executive Director:
|
Email: |
| Contact Name
(if different): |
Email: |
| Title:
|
Phone: |
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| ORGANIZATION’s
Mission |
| Brief statement of
organization’s objectives and/or activities |
| (Please attach
additional correspondence as desired) |
| |
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Organization annual operating budget:
$ |
Organization Audited? |
Yes |
|
No |
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TAX STATUS |
|
(Please fill in and attach a copy
of your organization’s IRS determination letter where applicable) |
| Tax Status
(choose one): |
501(c )(3): |
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Faith-based Institution: |
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Other: |
|
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Not a nonprofit
organization, per IRS; we have a fiscal sponsor: |
|
|
Sponsoring Organization*: |
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| Legal Name, per IRS
determination: |
| Tax ID #:
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Date of Incorporation:
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| *Please
submit letter by Sponsoring Organization stipulating they have agreed
to serve in this capacity. Please also submit a copy of the Sponsoring
Organization’s tax determination letter. |
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|
Summary of Request |
|
Project/Program Title: |
| Total
Project/Program Budget: |
| Amount
requested from The Marian Cooper Community Foundation: $ |
| Timeframe for amount
requested: |
From: |
To: |
|
Describe use of funds requested:
(i.e. staff costs, consultant fees, materials,
equipment) |
|
If grant request does
not equal total project/program budget, please list other sources of
revenue. |
|
|
Project/Program Summary |
| Summary of
Project or Program (briefly
describe the equipment, training or program, its objectives or
significance) |
|
| Who will this
project/program serve? |
| (special
populations, geographic area, community focus, organizational focus,
etc.) |
| |
|
| Specific,
Measurable Short-Term Outcomes |
|
(changes as a result of what you do, during the life of the grant or
as a result of the grant) |
| 1. |
| 2. |
| 3. |
|
| Measurable
Long-Term Objectives |
| (changes that
will result based on what you do, beyond the term of the grant) |
| 4. |
| 5. |
| 6. |
|
|
COLLABORATIONS AND other SUPPORT |
| Please tell us
if you are collaborating with any other organizations. |
|
|
Community Development/Involvement |
| Please list any
other organizational projects/initiatives that support community
development/involvement. |
|
|
Comments |
| Is there any
other information we might need to better understand your request
and/or the unique needs of this request that will serve the community? |
|
|
Required Attachments* (one copy) |
|
IRS tax determination letter
(where applicable)
Current board list including
professional affiliations
Current year operating budget
|
|
Optional Attachments (one copy) |
| Any supporting project
information for consideration |
|
*For applicants utilizing a fiscal
agent, the fiscal agent must submit all the required attachments. The
applicant should also submit all available attachments. If your
organization has submitted the above organization documents within the
past year, new information is not required. |
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________________________________________________ |
_________________ |
|
Signature |
Date |
|
__________________________________________ |
_______________ |
|
Printed Name |
Title |
| |
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Only completed applications with all
required attachments will be considered |
|
Please submit
your completed application to: |
|
The Marian Cooper Community
Foundation |
|
Grant Applications |
|
310 Prospect Hill Rd |
|
Cuddebackville, NY 12729 |
|
Email:
webmaster@choey.org |
|
|
This form may be downloaded from our website at
www.choey.org under
Application |
|
| If the
Foundation can be of assistance to you as you prepare your grant
application, please feel free to contact our organization at
webmaster@choey.org |