Fillable William and L.R. Gale Community Foundation a/k/a Galeton (C&N)

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William and L.R. Gale Community Foundation a/k/a Galeton (C&N)

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1
William and L.R. Gale Community Foundation
a/k/a Galeton Foundation
Grant Application
Galeton Foundation
c/o C&N Wealth Management, Trustee
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 religious, charitable,
scientific, literary and educational purposes or for the prevention of cruelty to children or animals within the
geographic areas of the Borough of Galeton and its environs but all within the County of Potter 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.
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 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
NAME ADDRESS
3
NAME ADDRESS
NAME ADDRESS
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
Summarize your organization’s mission: ________________________________________________________
Total Cost of Project: $__________________________
Total Amount Requested: $ ___________________________
PROPOSED USE OF REQUESTED FUNDS AND HOW IT WILL BENEFIT GALETON:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
4
FINANCIAL INFORMATION:
List other private and public funding sources for this particular request:
RECEIVED:
Funding Source: ________________________________ Amount: $____________ Date Received: ________
Funding Source: ________________________________ Amount: $____________ Date 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: ________
Funding Source: ___________________________________________ Amount Requested: $___________
Anticipated Receipt Date: ________
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): $_______________________
5
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
2010 $ _________ $ _________ $ ________ $ _______ ______________________________
2011 $ _________ $ _________ $ ________ $ _______ ______________________________
2012 $ _________ $ _________ $ ________ $ _______ ______________________________
2013 $ _________ $ _________ $ ________ $ _______ ______________________________
2014 $ _________ $ _________ $ ________ $ _______ ______________________________
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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William and L.R. Gale Community Foundation aka Galeton (C&N)

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Completed 10 August 2021

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