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2. Organization Contact Information

4. Name of Organization*
6. Does your organization have a federal tax ID?*

   1. Yes

   1. No
7. Tax Exempt?*

   1. Yes

   1. No
9. Executive Director or Project Manager*
11. Address 1*
13. Address 2
15. City*
16. State*
17. Zip*
19. Phone Number*
20. Email Address*

24. About the Organization

26. Mission Statement or Objective of the Organization*
28. Provide a brief history of the organization including the year founded
30. Identify the individual(s) who hold fiscal responsibility for the organization*
32. What auditing system or procedure does the organization use?*

36. Project Details

38. Please provide a description of the project (use additional pages if necessary)
40. Amount Requested
41. Period grant will cover

45. Funding Sources

47. From what other agencies has the organization requested funding?
49. • Name of Agency
50. • Dollar amount contributed

54. Organization Budget

56. Please provide the following information related to the organization’s current year’s budget:

58. Number of Staff

    Total paid, volunteer & intern positions

59. Salaries and Wages

    Total costs for paid staff

61. Real Property Budget

    Budget for all fixed property

62. Other Expenses

    Including travel, supplies, training, etc.

64. Income Funding Sources

    List and specify amounts of grants, contributions, fundraising, membership fees, etc.

66. Anticipated budget for the funds currently being requested through this program
68. Subtotal
69. Tax
70. Grand Total
74. Supporting documents

    The upload field above only accepts a single file.  To upload multiple files, you may create a zip archive: Microsoft - Zip and unzip files.

78. This application must be signed by a person with executive, fiscal management responsibility. The undersigned affirms the statements made in the application are true and complete to the best of the applicant’s knowledge. The applicant accepts as a condition of the grant, the obligation to comply with all state and federal requirements, and regulations.in addition, the agency agrees to comply with Gov’t. Code Section 8355 in matters relating to providing a drug-free workplace.

80. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
82. Name*
83. Title
84. Date
    Date

    Date
Leave This Blank:


86. Submit

* indicates a required field