FIVE BRIDGES FOUNDATION
GRANT APPLICATION
IMPORTANT: Submit this form ONLY if a Preliminary Proposal has been approved. Do NOT furnish materials not specifically called for by this form. You may retype this form, provided the information called for on this first page is shown on your first page, in the same order. Please submit one original and FIVE COPIES of this form, ONE of which must be manually signed. We need only ONE set of attachments.
Mail application and attachments to: Five Bridges Foundation, P.O. Box 194405, San Francisco, CA 94119-4405.Please use regular mail. Do not send by any means that might require a signature or return receipt.
SECTION I.
Date: ______
A. Legal name of organization:
B. Legal name of fiscal sponsor, if applicable. (See Section V, Paragraph F):
C. Mailing address:
City:County: State: Zip:
D. Contact person:
E. Phone number: Email address:
F. Fed Tax ID #:Date of latest IRS Determination letter:
SECTION II.
A. Amount requested: $______.
B. Type of support: Project ____ General Operating ____ Other ____
(The information contained in the approved preliminary proposal pursuant to which this application is being filed is incorporated in this application and is complete and correct except as set forth in an attachment to this application.)
SECTION III.
A. Current year organizational budget: $______.
B. Current year total project budget (if applicable): $______.
C. Most Recent Three-Year Financial History of Organization (please insert year):
1st Prior year 20____ Revenue $______Expenses $______
2nd Prior year 20____ Revenue $______Expenses $______
3rd Prior year 20____ Revenue $______Expenses $______
D. Please provide an explanation of any major fluctuations or changes in revenue and/or expenses in the past three years:
SECTION IV.
A. Please attach a copy of the budget of the project for which the requested grant funds will be used. List any funds needed in excess of those requested from Five Bridges and specify the source of such funds.
B. Please attach a complete copy of Applicant’s most recent full and partial year to date Statements of Financial Position (Balance Sheet) and Statements of Activities (Statement of Operations or Profit and Loss Statement). Audited financials are required for all organizations with budgets over $2 million. Organizations with a fiscal sponsor must also submit audited financials of the fiscal sponsor.
Are these complete and correct, to the best of your knowledge? ____Yes ____No
C. Please attach a list containing the names and addresses of Applicant’s directors and principal officers.
D. Please attach the names of the principal staff of Applicant, identifying the person or persons who will oversee the use of the requested grant funds. Please attach resumes of the latter person(s).
E. Please attach a copy of the most recent United States Internal Revenue Service determination letter establishing the tax exempt status of Applicant.
By filing this Application, you certify that Applicant (or its fiscal sponsor) is a corporation that has received formal advice from the tax authorities of the federal government and the state(s) in which it operates that it is a tax exempt 501(c)(3) public charitable corporation under §501(c)(3) as described in §509(a)(1) or §509(a)(2), but not §509(a)(3) of the U.S. Internal Revenue Code, which exemptions have not been suspended or revoked and are presently in effect. Yes_____ No_____
F. For prior grantees, please attach Report(s) not previously submitted. (To be eligible for current funding, required reports on prior grants must have been submitted.)
SECTION V.
A.The undersigned individual represents that he or she has full legal authority to execute and deliver this Application (including all attachments and exhibits) on behalf of Applicant and that when signed and delivered it will be fully binding on Applicant.
B.The undersigned individual and Applicant represent that all information contained in this Application (including all attachments and exhibits and the Preliminary Proposal that preceded this Application) is, and in any supplements and reports will be, full, true and correct to the best of their knowledge and belief.
C.Applicant agrees that, except as expressly set forth in the letter awarding the grant from the Foundation, all funds awarded by the Foundation will be used solely for the purposes specified in the approved Preliminary Proposal and in this Application within 12 months from the date of the receipt of the grant and that Applicant will promptly refund to the Foundation any portion of the grant funds not so used.
D.Applicant agrees that any work product of the project funded by the grant will be made available to the public as provided in the Application or the letter from the Foundation awarding the grant.
E.Applicant agrees to provide the Foundation in writing such interim reports on the use of the grant funds as may be requested and that it WILL SUBMIT A FINAL REPORT promptly upon completion of the project or expenditure of the grant funds if sooner. (See Report Form on Five Bridges Foundation website:
F. If Applicant has a fiscal sponsor, the fiscal sponsor must sign this application and is responsible for full compliance by Applicant with all of the terms and conditions of this Application.
SIGNATURE
Legal name of Applicant (or Fiscal Sponsor) as set forth in Section I above.
______
By (signature) ______
Name of Signer (please print)______
Title of signer ______
Date of signing ______
(Revised 01/08)
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