Lummi Nation

Community Contribution Application

DEADLINE: January 16, 2013

TO BE ELIGIBLE, THE FOLLOWING ITEMSMUST BE INCLUDED IN THE APPLICATION:

Complete Community Contribution Application

Project Budget

Copy of IRS Final Determination 501(c)3 Letter AND Proof of Non-profit Status within the State of Washington

Completed W-9

There are five (5) separate fund categories, please select the category you are applying for:

Community Contribution: funds that can be distributed to non-tribal local governmental agencies, for reimbursement for actual or potential impacts from Class III gaming activities.

Charitable Donations: funds for non-tribal bona fide nonprofit and charitable organizations in the State of Washington. Non-tribal meaning it cannot be owned by the Lummi government. Other Tribes who have bona fide nonprofit or chartable organizations are eligible to petition for funds. Lummi Nation controlled programs are not eligible for these funds.

Community Impacts: These funds are for tribal governmental programs that promote the tribe and its members to become self sustaining.

Problem Gambling: funds dedicated to problem gambling education, awareness, and treatment in the State of Washington. Lummi Nation programs can petition for these funds.

Smoking Cessations: funds dedicated to smoking cessation, prevention, education, awareness, and treatment in the State of Washington. Lummi Nation programs can petition for these funds.

Lummi Nation

Charitable Contribution Application

Date: ______

Name of Applicant: ______

Contact Person: ______Phone Number: ______

Address: ______

City, State, Zip: ______

Program Name: ______

Amount Requested: ______Total Budget: ______

Number of people benefited: ______Number of Lummi Tribe benefited: ______

Duration of Project: From:______to: ______

EIN Number: ______

**Please attach a copy of the organizations 501(c)3 Determination Letter and a signed W9. Request will not be considered nor funds distributed without these documents.

Funding Category

__ Youth/Education__ Community Outreach__ Elders

__ Youth/Sports__ Adult/Sports__ Other

Give a brief (50 words or less) summary of your program and the reason for this grant request:

______

Briefly describe how your program would the Lummi Nation and the surrounding area:

______

What is your organization’s mission? What part of the community is served by your organization? Is the organization staffed by volunteers, or is the staff paid?

______

Do you expect funds from other sources to carry out the project? If so, from whom?

______

Total Project Budget

Organization Name: ______

Name of Project (if different): ______

Budget dates for grant period: ______

INCOME

Possible categories: Government grants, other foundation grants, individuals, business support, events, fees for service, ect.

FUNDING SOURCE / POTENTIAL ($) / SECURED ($) / NOTES
TOTAL INCOME

List the In-Kind (non-cash) contributions: ______

______

EXPENSES

Possible categories: Salaries, professional fees, rent and utilities, travel, publicity/outreach, events, capital items, etc.

ITEM / TOTAL PROJECT ($) / THIS REQUEST ($) / NOTES
TOTAL EXPENSES

Submission of Application:

Applications are reviewed after each deadline. Please attach a copy of your IRS 501(c)3 letter ruling or a completed W9 Form.

Submit Application on or before the deadline to:

Stephanie Toby

Lummi Indian Business Council

2616 Kwina Road

Bellingham, WA 98226

Phone: 360-306-8250

If you have any questions concerning the application or its status please feel free to email Stephanie Toby at

PLEASE NOTE: Unfunded Applications are not retained. Entities are eligible for funding once per year. Missing signed W9 or 501(c)3 verification form will delay or hinder successful consideration of funding request.

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