Community Impact Grant Application

Name*

Organization's Name

Phone*

Email*

Address*

Street Address City State ZIP Code

Program Details

Amount Requested*

(X,XXX.XX) No $ required.

If the request is partially funded, will the project/program still be viable?*

Yes
No

Total Program Budget*

(X,XXX.XX) No $ required.

Program Budget Summary*

Please provide a detailed summary of how the funds for your project or program will be allocated, emphasizing how and where the funds granted from the Community Impact grant will be utilized. Bullet points are fine. Be specific.

Projected Program Start Date*

Program Title*

Type of Request*

Please fill in the type of request*

What is the primary purpose of the request?*

What counties will this program serve?*

Carroll
Haralson
Heard

Project/Program Narrative*

Describe the problem/opportunity that the grant will address in a brief narrative. Limit your response to a maximum of 1500 words. Please include the following in your explanation: * Specifically, what is the problem or opportunity to be addressed and how will the grant address the problem/opportunity? * How would you use the Foundation's funds to address this problem/opportunity? * What are the goals/objectives of the program? How will they be measured? * Who are the targeted groups that will benefit?. * Identify in your narrative other collaborations or partnerships with other groups to accomplish your goal(s).

Are the beneficiaries of the program required to do anything specific?*

ex: attend religious services/training or pay a fee to participate in the program?

No
Yes

If yes, please describe below*

Organizational Structure

Do you have 501(c)(3) certification?*

No
Yes
Not Applicable

Please note date 501(c)(3) certification acquired

Please attach copy of 501(c)(3) certification letter

Federal Tax #ID*

Date Incorporated*

Describe the mission and summarize the history of the organization. What are the organization's main activities or programs?*

Limit your response to 1,500 words.

Please attach a list of the current Board of Directors, including their address and occupations:*

Number of paid employees*

Number of volunteers*

Financial Information

What is the total operating budget of your organization?*

If awarded, what percentage of your budget will consist of Community Impact funds?*

What other sources of financial support will be used to fund this project?*

Community Impact Grant Application

Step 1 of 2

Program Details

Organizational Structure

Financial Information

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