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1200 (Salt Lake County)

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  • 6 check-boxes
  • 53 other fields

Country of origin: US
File type: PDF

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RECIPIENT ORGANIZATION’S DISBURSEMENT
OF FUND REPORT
This report is REQUIRED for all contributions more than $2,500.
This report is to be filed with the Council and Mayor’s Offices within six months of receipt of
the money. If further contributions are desired, the report must be filed with the Council and
Mayor by September 1
st
of each year.
CONTRIBUTION AMOUNT: _________________
DATE RECEIVED: _________________________
Please describe
how the money was spent and how this funding contributed to the success of your
organization.
Dated this _________ day of _______, ______. Recipient_________________________________
NAME OF ORGANIZATION: __________________________________________________________
ADDRESS: ________________________________________________________________________
CITY: ________________________________ STATE: ____________ ZIP
CODE: _____________
CONTACT PERSON: ________________________________________________________________
PHONE NUMBE
R: __________________________ E-MAIL: _______________________________
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APPLICATION FOR CONTRIBUTION
STATE:
NAME OF ORGANIZATION:
ADDRESS:
CITY:
CONTACT PERSON:
ZIP CODE:
What is the amount of your request?
The amount you are requesting is ________ of your annual agency budget.
What is the purpose of the money you are requesting?:
PLEASE ATTACH:
Copy of organizations nonprofit status.
Copy of independent audit. If you do not have one, please enclose a copy of current financial statements.
Dated this _________ day of _______, _____. Applicant ___________________________________________
PHONE NUMBER:
EMAIL:
ORGANIZATION OVERVIEW (which could include mission, history, and demographics served):
TYPE OF REQUEST: Money __________ In-Kind __________
Have you previously requested money from SLCo? __________
If yes, when and how much (previous three years)?
You will be expected to report to the Salt Lake County Mayor on how the money was used and the success of the project.
The undersigned hereby acknowledges that he or she has authority to bind the organization listed in the application. The
applicant accepts the following terms and conditions as a condition of receiving and using County funds or the waiver of
fees: County funds will be used solely for the purposes approved by the Mayor of Salt Lake County as applied for in this
application. Any expenditure for purposes other than those approved w
ill require a return of the entire grant amount and
may disqualify the grantee from receiving any additional County funds. It is further understood that no grant fund will be
made available to any County officer of employee or in violation of the requirements of the Public Employees Ethics Act
(67-16-1 et seq.). No grant funds will be used for political or campaign purposes. As a further condition of the grant, all
County funds may be subject to an audit as required by Salt Lake County. The applicant is required to complete the
Disbur
sement of Funds Report Form for contributions more than $2,500.
0.00%
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APPLICATION FOR FEE WAIVER
STATE:
NAME OF ORGANIZATION:
ADDRESS:
CITY:
CONTACT PERSON:
ZIP CODE:
ORGANIZATION OVERVIEW (which could include mission, history, and demographics served):
Have you previously requested a fee waiver from SLCo?
If yes, when and for what facility?
What fees are you requesting be waived?
Fee waiver value $
Please describe your justification for requesting the fee waiver:
PLEASE ATTACH:
Copy of organization's nonprofit status.
Flyer, invitation or event announcement.
Copy of independent audit. If you do not have one, please enclose a copy of current financial statements.
The undersigned hereby acknowledges that he or she has authority to bind the organization listed in the applicant. The
applicant accepts the following terms and conditions as a condition of receiving and using County funds or the waiver of
fees: County funds will be used solely for the purposes approved by the Mayor of Salt Lake County as applied for in this
applicant. Any expenditure for purposes other than those approved will require a return of the entire grant amount and
may disqualify the applicant from receiving any additional County funds. It is further understood that no grant fund will be
made available to any County officer of employee or in violation of the requirements of the Public Employees Ethics Act
(67-16-1 et seq.). No grant funds will be used for political or campaign purposes. As a further condition of the grant, all
County funds may be subject to an audit as required by Salt Lake County. The grantee is required to complete the
Disbursement of Funds Report Form for contributions more than $2,500.00.
Dated this _________ day of _______, _____. Applicant ________________________________________
PHONE NUMBER:
EMAIL:
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1200 (Salt Lake County)

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Completed 14 February 2021

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