Fillable 846 GRANT REQUEST FORM

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846 GRANT REQUEST FORM

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The 846 GRANT REQUEST FORM form is 3 pages long and contains:

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  • 6 check-boxes
  • 80 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Grants Pass

BROWSE CITY OF GRANTS PASS (OR) FORMS

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Josephine County/City of Grants Pass Solid Waste Agency Effective 7/01/2018 G:\AGENCIES_COMMITTEES\AGENCIES\SW AGENCY\Funding Requests
Page 1 of 3
FUNDING REQUEST APPLICATION
Date:
Funding Request Amount:
Applicant/Company Name:
Contact Name (If different):
Physical Address:
Mailing Address:
City: State: Zip:
Phone: Cell: Fax:
Email address:
Project Name:
*Funding request is for reimbursement only after receipts are submitted.
Guidelines for Preparing your Proposal/Funding Request
Fill out this form completely and legibly.
Include one-page abstract/overview of your organization.
Copy of most recent financial statement including balance sheet and summary of operations
(audit if available).
Any other relevant information you wish to include.
Description of any pending legal matters.
Return entire packet to City of Grants Pass, Public Works Department, 101 NW A Street, #205
Grants Pass, OR 97526, 541-450-6110; fax 541-479-6765.
Overview Exhibit: Attach separate Summary Page, as Exhibit 1 showing:
a. Mission Statement
b. Short history of your organization.
c. Makeup: Board? Budget Committee? Organizational system?
d. Employee Makeup: current list; positions; relationship to the project.
e. Partners: People and organizations who commit resources to the Organization?
Indicate how they work with you and support the operation.
Solid Waste Agency Use Only
Date Application received:
By:
Disposition:
Date:
Josephine County/City of Grants Pass Solid Waste Agency Effective 7/01/2018 G:\AGENCIES_COMMITTEES\AGENCIES\SW AGENCY\Funding Requests
Page 2 of 3
QUESTIONNAIRE
SECTION I - ORGANIZATION
Background Information
Director/Manager Name:
Date Organization Established:
Tax Status (nonprofit, for profit, Government Agency, etc)
SECTION II - REQUEST:
1. Summary: Provide a one-page summary.
2. Description: Provide a description of your project request. Include specific information
describing how the requested funds will be used.
3. Project Goals: Describe the specific goals and measurable objectives of the project.
4. Yardstick: Describe how you will evaluate whether you have achieved your measurable
objectives.
SECTION III - LEGAL
Does your organization have any open matters of litigation currently pending?
Yes No If yes, please explain in an attachment to your funding request.
SECTION IV - FINANCIAL INFORMATION
1. Budget: Please include a copy of your current year budget.
2. Does your organization have any outstanding debt? Yes No
If yes, please delineate the amount and the reasons for the debt.
________________________________________________________________________
________________________________________________________________________
Is your organization’s budget in deficit? Yes No
If yes, please explain why.
________________________________________________________________________
________________________________________________________________________
Is this your initial request for funding from the Solid Waste Agency? Yes No
If no, when and how much funding have you received? ________________.
3. Project Budget: Please include a copy of the budget specific to the project proposed for
Solid Waste Agency funding.
4. Provide specific information pertaining to any donations or in-kind services your
organization anticipates for this project as listed above.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Josephine County/City of Grants Pass Solid Waste Agency Effective 7/01/2018 G:\AGENCIES_COMMITTEES\AGENCIES\SW AGENCY\Funding Requests
Page 3 of 3
5. If applicable, list other anticipated sources of funding, funding amount and status of
request (when listing sources of funds, give a detailed breakdown, using an additional
sheet if necessary).
SECTION V - VOLUNTEER PARTICIPATION
1. Estimated number of volunteers who have provided service to the organization in the past
year: ________________
2. Estimated number of volunteer hours in the past year: ____________ hours.
3. Description of any volunteer groups:
____________________________________________________________________________
____________________________________________________________________________
SECTION VI: - PUBLICITY/PROMOTION
Prominent acknowledgement of the Josephine County/City of Grants Pass Solid Waste Agency is
required of all recipients for use in all publicity materials, including, but not limited to brochures, press
releases, programs, posters, public service announcements, flyers, newsletters, and advertisements in
regards to this particular project following funding approval by the Agency.
SECTION VII - QUARTERLY REPORTS
All agency funded recipients are required to make quarterly reports, and present the results at
regularly scheduled Agency meetings regarding the status of the project.
SECTION VIII: - ACCURACY
I hereby certify, to the best of my knowledge and belief, that the information submitted with this request is
accurate and that the attached budget was approved by our governing board. We also agree to allow the Solid
Waste Agency to review the books and records of the applicant should they so desire. Undersigned is
authorized to sign and bind the applicant.
_______________________________________ __________________________
Signature Date
Title __________________________
Funding Source
Name the Partner and
their contribution.
Cash
In-
Kind
Secured
(x)
Pending
(x)
Total Amount/Value
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Total Estimated Funds (add all amounts in the far-right Column):
$
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846 GRANT REQUEST FORM

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Completed 12 July 2020

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