LOCAL CONTRIBUTIONS APPLICATION

(Henderson Operations and Climax Mine Operations)

IMPORTANT NOTES:

-This Application should only be completed if the requested amount is less than $10,000

- Requested amount may not be for more than 50% of the project budget or to support annual operating funds

- Please be sure to also submit the organization’s Form W-9

- Application should not exceed the 4 pages allotted (excluding signature page)

- Please be sure to complete each question. Incomplete questions may cause an application to be ineligible

ORGANIZATIONAL OVERVIEW

Date of request:
Name of organization requesting funds:
Name / title of main contact person:
Phone number:
Email address:
Mailing address:
Total (annual) organization budget:
Organizational status: / [ ] 501c3 [ ] 501c6 [ ] government
[ ] other (please specify):
Name of project or activity:
Grant amount requested:
Date donation is required: (if applicable)
Total project budget / cost:
Project or activity START date:
(if applicable)
Project or activity END date:
(if applicable)
Check the Focus Area / Category
For which You Are Applying: / Does your project address a special population?
Education
Environment
Cultural Preservation & Heritage
Economic Development
Health & Wellness
Youth
Social Services
Transportation
Citizen Involvement
Outdoor Recreation & Tourism
Other (please describe) / Women’s Development
Senior Citizens
Other (please list):
Please describe the project for which you are requesting funds.
Please describe the geographic area you currently serve and the geographic area that the project will serve.
Is this a one-time project or event?
If ongoing, how long has the event occurred?
[ ] Yes [ ] No
If ongoing, how long has the event occurred?
Have you received funding from Climax Molybdenum or Freeport-McMoRan in the past?
[ ] Yes [ ] No
Will funding from Climax Molybdenum help you to secure additional funding for the project? If so, how?
Please list any other partners in this project who are providing funds or other resources. (Please list any known amounts that have been or will be provided):
How might a donation support a sustainable benefit to the community, the program or your organization? What do you believe the sustainable benefit might be?
Please list any Climax Molybdenum/Freeport-McMoRan employees that you know are involved in your organization (such as volunteers, board members or donors)

Support Documentation Required (please check the boxes to ensure these items are attached)

Copy of 501c-3 status letter from the IRS or Related Certification

Copy of Form W-9

Detailed Project Budget (including other sources of funding/income)

Current Board of Directors list (if applicable)



SUBMITTING APPLICATION:

Please return this application and required documents via e-mail to one of the following contacts.

If you have questions, please feel free to call or email.

Tara Hosick, Community Development Manager

Phone: 303-860-8048

E-mail:

Nell Bailey, Community Development Specialist

Phone: 720-343-8013

E-mail:

STATEMENT OF UNDERSTANDING

If awarded, contributed funds must be used for developing and implementing the project as described in this application. Climax Molybdenum has the right to disseminate information and materials developed as a result of the project.

Signature: