Grant Application Form - Lake County Community Foundation

Date

Please Check one

New Request
Renewal Request

ORGANIZATION NAME

Address, City, State, Zip Code

County, Website, Phone #, Email

EXECUTIVE DIRECTOR OR BOARD CHAIR (name, title, email)

Counties where services are provided:

Employer ID number (EIN), year organization established

Number of paid employees, Number of volunteers, Number of board members, Number of board meetings per year.

ORGANIZATION FINANCIAL INFORMATION, Budget for current year, organization expenditure total for last year, Organization revenue total for last year.

From last year's revenue sources, please list the five single largest contributors and amounts provided. (Contributors include specific individuals, agencies, businesses, foundations, or other groups. Individuals may be listed as anonymous.)

Please list grant applications to LCCF and amounts awarded during the past three years.

PROJECT CONTACT PERSON – Name, title, phone, email

Project description (one sentence)

How many persons will benefit directly from the project?

In what counties will services be provided through this project?

TOTAL PROJECT BUDGET / TOTAL REQUESTED

Other proposed sources of funding and amounts for each. (Please note if funding is secured with "yes" or "no".

NARRATIVE, please answer the following questions.

Describe your organization. What is your mission?

What does your project address: What critical community problem needs to be fixed?

How will you do it? What are the specific activities to be supported?

Who is responsible for your project? Briefly describe your project leaders and the role that each will play.

How will you measure results?

CONCLUSION – Why do you think this project fits "People helping people create a better Lake County by giving where they live"? Why does it matter to your community?

With my signature (printed name will count as signature) and date, I certify the following :(1) The above information is correct; (2) I am authorized by the governing board of this organization to submit this grant application to the Lake County Community Foundation; (3) this organization is in good standing with the IRS, retains its 501 (c)(3) tax-exempt status and is further classified as a public charity and not a private foundation; (4) this organization does not discriminate on the basis of race, religion, sexual preference, physical curcumstances or national origin.

Required – ONE complete package that includes: application summary and narrative, detailed project budget, including revenues and expenditures, list of board of directors with affiliations and phone numbers and organization 501(c)(3) determination letter from the IRS. Click "submit" to email the application or print it and mail it to:Lake County Community Foundation Attn: LCCF Board Member, 126 North E Street, Lakeview, OR 97630