Community Crisis Relief Fund Application for Nonprofit AGENCIES Organization Information Organization Name Contact Name Title Mailing Address City State Zip Code Is the physical address different? - Select -Yes No Physical Address Street Address City State Zip Code Telephone Fax Number Email IRS EIN Number Funding Request Project Name Project Description Total Amount Requested (Grant requests will be limited to a maximum of $2500 per organization, per requests) Does your agency/organization serve all of Marshall County? - Select -Yes No If not, please list all of your service areas. List any organizations or volunteer groups partnering with you on this project. Project Time Frame Project Budget See example: If granted the amount of your request, how many additional individuals will you be able to serve per month? (If applicable) Has your agency/program received Community Crisis Relief Funds in the past? - None -Yes No If yes, has your agency spent all of the funds awarded in your previous Community Crisis Relief Fund grant? Required Attachments Upload your IRS Form 990 for the most recently completed tax year, including Schedule A (if applicable) Only necessary if United Way does not have your most recent on file.One file only.200 MB limit.Allowed types: jpg, jpeg, png, pdf. Upload your most recent audit OR agencies without an audit or agencies with an annual budget less than $100,000, please include a Statement of Financial Position and/or current annual operating budget (revenues and expenses) Only necessary if United Way does not have your most recent on file.One file only.200 MB limit.Allowed types: jpg, jpeg, png, pdf. Upload your current year operating budget as adopted by your board of directors. One file only.200 MB limit.Allowed types: jpg, jpeg, png, pdf. Upload your most recent Profit and Loss statement (either last month or last quarter) One file only.200 MB limit.Allowed types: jpg, jpeg, png, pdf. Upload board meeting minutes or other communication documenting board's decision to seek United Way funding for specific projects or to cover operating shortfalls. One file only.200 MB limit.Allowed types: jpg, jpeg, png, pdf. Authorization Typing your name below is an agreement to the following statement: I certify that the information contained here is true and correct, and that any funding received as a result of this application will be utilized in a manner that is consistent with the proposed purposes of the projects and/or programs described. I understand that at any time, United Way of Marshall County may request documentation related to any grant received, including verification of unduplicated clients and expeditures. Authorized Signature
