Date of Application:

Name of Organization:

Project Name:

Amount Requested:

Main Contact Information

Name: Title:

Address: City: State: Zip:

Phone:

Email:

Organization Information
(If same as the Main Contact, write "same")

Legal Name (if different from above:

Street Address: City: State: Zip:

Phone:

Email:

Web site:

Year founded:

Mission statement: (max. 100 words)

Brief history of Organization: (max. 100 words)

Please check any of the following that apply:

Grassroots (not Incorporated) Incorporated Nonprofit

If Incorporated, what state? Date of Incorporation:

501(c)(3) 501(c)(?)

Does organization have an Employer Identification Number (EIN)? Yes No

If yes, provide it here:

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Project Information

Name of Project:

Physical Location:

Brief History: (max. 100 words)

Issues/problems to address: (max. 100 words)

Who benefits and what to achieve? (max. 150 words)

Anticipated Beginning Date: Ending Date:

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Personnel
Please give names, titles and one sentence of qualification for the people who will be implementing the project.

Name: Title:

Qualification:

Name: Title:

Qualification:

Name: Title:

Qualification:

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Signatures
Please type name, title of CEO, President, or Executive Director

Name: Title:

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Attachments
Please include any of the following that apply to your organization.

Attachments can be mailed to PO Box 452, Red River NM 87558 or emailed to rrvf@redrivervalleyfoundation.org. (If you have only online email, type or paste this address into the "TO:" line in that email.) Be sure and identify all attachments with the contact person, organization and project name.

• Board of Directors. (Name, title, one sentence about her/his role in the community)
• Organization year-end financial (revenue/expense) statement
• Most current balance sheet
• Project budget

List sources of revenue and amounts for the project. These may include donations, foundation grants, government grants, fees for services, sales, other.

List project expenses:

Allowable expense line items include: salaries, contracted personnel, travel, fundraising, equipment, supplies, telecommunications, public relations, rent, utilities, insurance, staff training, board training.

Not allowable line items: mortgages, debts, interest, law suits, judgements, capital improvements (buildings/renovations).