Recipient Organization Grant Application Form

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Organization Name:

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Phone Number:

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Mission/Purpose Statement:

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Amount of Funds Requested:

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Reason:

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How many people will these funds impact?

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Who is in charge of making sure these funds are properly utilized?

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What month does your fiscal year end?

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EIN#

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as part of accepting your funding request, ADFCOF required a copy of your approved IRS Determination letter verifying your exempt status, or that you have filed your 1023 application, pending their approval, and an annual accounting of how these funds were utilized no later than three (3) months beyond your fiscal ending month.

Application submitted by

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Job Title:

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and we agree to the aforementioned terms as stated above and below.

Recipient Agency Representative Electronic Signature:

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Date of Submittal:

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Applications for financial assistance are accepted quarterly, starting July 1-9, 2011, and thereafter on, October 1-9, January 1-9, and April 1-9 annually. Your application to receive funds shall be processed no later than the second week of the following month after receipt and scored by an impartial Selection Committee. Notification of any/all awards will be issued via email, phone and/or US mail. The grant award is non-transferable, and no substitution or cash equivalent is allowed. All awards or denials are final.

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Recipient Organization Grant Application Form

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