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THE CHAMBERS FAMILY FOUNDATION
THE CHAMBERS FAMILY FOUNDATION
Grant Application
One copy of this application, along with a proposal and the other items described in the Grant Application Guidelines, should be mailed to: The Chambers Family Foundation, 800 Willamette Street, Suite 750, Eugene Oregon 97401. Additionally, if you have received funds from us in the past, please attach a brief report on how those prior grants were used.
Organization Founding Date
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Physical Address
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Mailing Address
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Project Contact Person Title Phone
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Executive Director Phone
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CEO / Chairperson of Governing Board Phone
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Information About Project for Which Funds are Requested
Objectives and description of project
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Specifically, how will The Chambers Family Foundation funds be used?
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Total project cost Amount requested from The Chambers Family Foundation
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$$
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Amount and sources of contributions/pledges for project to date
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Other funding sources from which support is requested
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Project period: (number of months) Beginning
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Geographical area (counties) to be served by project
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Client group (and number) to be served by project
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Number Served Monthly Number Served Annually
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Information About Applicant Organization
Purpose of Organization
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Tax exempt status (If exempt under another organization, send evidence from the IRS of that exemption and the relationship between the exempt organization and the applicant organization):
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501(c)(3) Organization name on IRS letter?
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Is tax exempt status currently valid?
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Organization financial information (Do not include in-kind contributions)
ENDING DATE OF FISCAL YEAR
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Budget for current fiscal year:
Income:Expenditures:
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Major sources of support (and amounts)
Already committed:
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Expected:
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Financial statements for last fiscal year:
IncomeExpenditures
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Major sources of support (and amounts)
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Financial statements for the two fiscal years prior
Year Income Expenditure
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Year Income Expenditure
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Does the organization receive any United Way funding?
If so, how much last fiscal year? $Percent of budget
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%
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Does the organization receive any federal/state funding?
If so, how much last fiscal year? $Percent of budget
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%
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If a grant is awarded, what is the organization name to which checks should be made payable (if different from above)?
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I certify that the above information is correct and that I am authorized by the governing board of this organization to submit this grant application to The Chambers Family Foundation.
Signature of Chief Executive Officer:
Date Printed Name:
For Office Use Only
Application Complete _____ Letter and/or Narrative _____Prior Grants _____ Project Budget
Financial. Statement _____ Board _____ 501(c)(3) IRS Letter _____ Proposal Complete
Process: _____May 201__ Process: November 201__ Proposal Incomplete: Notify Applicant