Fillable Baker Foundation TUW Grant Application Baker Foundation c/o (C&N)

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Baker Foundation TUW Grant Application Baker Foundation c/o (C&N)

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1
Baker Foundation TUW
Grant Application
Baker Foundation
c/o C&N Wealth Management
P. O. Box 58
Wellsboro, PA 16901
((800) 487-8784
[Please verify that your request is consistent with the Mission of the Foundation.]
Mission: This Trust and Foundation is created and shall be operated exclusively for youth-based charitable,
scientific, literary or educational purposes, or community benefits within the geographic areas in the vicinity of
Deerfield Township and its environs but all within the County of Tioga and Commonwealth of
Pennsylvania.
After the above foundation receives a request for a grant application, a copy of this application will be
mailed to the Applicant. The Applicant should return the completed application to the
foundation at the above address provided. The Administrative Committee of the foundation will review
the application and make a determination for the grant distribution at their next regularly scheduled meeting.
Applications will be reviewed twice a year with deadlines being April 1
st
and October 1
st
of the current year.
Instructions:
(a) All questions must be completed, if applicable.
(b) Applicant must be recognized by the Internal Revenue Service as a public charity with a 501 (c)(3)
Determination Letter in order for the Applicant to be considered by the Administrative Committee. A
copy of the applicant’s IRS Determination Letter, including Applicant’s charitable status must be
attached to the Application.
(c) If your organization is required to file IRS Form 990, please submit the most recent copy. If
organization is not required to file IRS Form 990, please submit most recent audit or current budget.
(d) For capital projects please submit a minimum of two bids for any grant requests in excess of $1,000,
contingent to award.
(e) A representative from your organization may be asked to meet with the Directors of the Baker
Foundation before your request is considered.
2
Date of Application: _______________
Name of Applicant Organization: ____________________________________________________
Address: _________________________________________________________________________
Street or
PO Box City State Zip
EIN: _____________________
Federal Taxpayer I.D. #
Phone: ___________________ FAX:__________________ Web Site: _____________________
Email Address: ____________________________
Contact Person: ____________________________________________ Title: ____________________
Contact Person Phone #:_________________________ Email Address: __________________
List All Directors/Trustees:
NAME ADDRESS
NAME ADDRESS
NAME ADDRESS
NAME ADDRESS
NAME ADDRESS
NAME ADDRESS
Is your organization an IRS 501 (c) (3) not-for –profit? Yes No
If yes, please make sure a copies are attached per (b) of the Instructions on page 1.
3
Summarize your organization’s mission: ________________________________________________________
Total Cost of Project: $_______________________________
Total Amount Requested: $ ___________________________
PROPOSED USE OF REQUESTED FUNDS AND HOW IT WILL BENEFIT THE COMMUNITY:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
FINANCIAL INFORMATION:
List other private and public funding sources for this particular request:
RECEIVED:
Funding Source: ________________________________ Amount: $____________ Date Received: ________
Funding Source: ________________________________ Amount: $____________ Date Received: ________
PENDING:
Funding Source: ___________________________________________ Amount Requested: $___________
Anticipated Receipt Date: ________
Funding Source: ___________________________________________ Amount Requested: $___________
Anticipated Receipt Date: ________
4
For applicants that are exempt from filing IRS Form 990, please supply the following information:
Gross Value or Net Worth of Applicant: $_________________________________
Annual Gross Income: $____________________________
Major Sources of Income: $___________________________
Total Debt (including credit card): $_______________________
Over the past five (5) years has the applicant ever received monies from any other Foundation? Yes ___ No
___. If so, indicate the following: Foundation, Date, Purpose, and Amount Received:
Name: __________ ________ ________ _______ Purpose
20__ $ _________ $ _________ $ ________ $ _______ ______________________________
20__ $ _________ $ _________ $ ________ $ _______ ______________________________
20__ $ _________ $ _________ $ ________ $ _______ ______________________________
20__ $ _________ $ _________ $ ________ $ _______ ______________________________
20__ $ _________ $ _________ $ ________ $ _______ ______________________________
Applicant will be notified of the action taken by the Administrative Committee. If a grant is awarded you
will be notified of the amount and the terms of your grant. Following completion of the project, you will be
required to submit a Grant Compliance Form.
If the project is not completed or is terminated, notify the Foundation immediately. If an applicant ceases to
exist, and it possesses property purchased with foundation money, the Applicant hereby agrees that it will
furnish any and all additional information required by the foundation in connection with the grant request,
and if applicable, will allow representatives of the Foundation to visit the premises involved with the grant
for inspection at any reasonable time.
Respectfully Submitted By: ____________________________________
NAMIE OF ORGANIZATION
By: ______________________________________________
SIGNATURE OF AUTHORIZED REPRESENTATIVE TITLE
Attest: By: ____________________________________________
SIGNATURE
SECRETARY OF ORGANIZATION
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Baker Foundation TUW Grant Application Baker Foundation co (C&N)

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Completed 10 August 2021

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