Community Fund Form

Name of Organization/Agency

Physical Address of Organization

City

State/Province

Zip/Postal

Mailing Address (if different)

City

State/Province

Zip/Postal

Phone Number

Contact Person

Email Address

Is organization exempt from payment of income tax?

Yes

No

Is organization deemed a Not for Profit approved by IRS?

Yes

No

Employer Identification Number (EIN)

Project Start Date

Project End Date

Total of Request - Maximum Amount $5,000

$

Please include a decimal point - Whole dollars only

Applicants must provide a copy of financial statement(s) for the most previous year.

Maximum file size: 32MB

Accepted file types are: pdf, docx, xlsx, jpg, jpeg, png, gif

If unable to provide a financial statement, please explain why.