If Yes, Provide Amounts and Dates for the Last Five Years

JUNE ROCKWELL LEVY FOUNDATION

Name and address of Organization:
Mailing address if different:
Telephone number: / Date:
mm/dd/yr
Email address:
Contact person: / Title:
Is your organization a 501(c)(3) ? / Yes No / Date so designated:
mm/dd/yr
Amount requested: / $
Have you ever received any grants from the Levy Foundation? / Yes No

If yes, provide amounts and dates for the last five years:

Month/Year / Amount
$
$
$
$
$

What are your total budgeted expenses for the current fiscal year? $

What are the salaries for your three most highly compensated employees?

Title / Annual Salary
$
$
$

2

JUNE ROCKWELL LEVY FOUNDATION

Name of organization:
Purpose: Briefly describe the history and mission of your organization:
Application: Briefly explain your application. Name other foundations and organizations which have agreed to financially support this proposal, listing the amounts. If this is an ongoing program, how will you fund it in future years?
Program Impact: Briefly explain how this proposal will impact on the communities and people of Northern Rhode Island (i.e., Providence County)?

Your Finances. Please show, for each of the last five years, your income, expense, profit or loss, and the percentage of your operating budget derived from governmental sources (grant, contract or otherwise). If you are showing a deficit, how do you finance it?

Year

/ Income / Expenses / Profit / Loss / % Derived from Governmental Sources
$ / $ / $ / $ / %
$ / $ / $ / $ / %
$ / $ / $ / $ / %
$ / $ / $ / $ / %
$ / $ / $ / $ / %

Foundation Support. For each of the past five years, describe grants received, and the purposes thereof, from your five largest foundation grantors (i.e., non-governmental donors). (Attach a schedule if more convenient.).

Year

/ Grantor / Amount / Purpose for Grant /
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Name Typed/Printed:
Title: / Signature
Date:

2