GARNEAU-NICON Family Foundation

Individual Grant Application

For

GARNEAU-NICON Family Foundation

Date: ______

1. Applicants Name ______

2. Address ______City: ______State: ______Zip: ______

3. Date of Birth ______Highest year of education completed______

4. Marital Status _____Number of Dependents ____ Ages of Dependents______

5. Are you now, or have you been the recipient of any other financial award? If yes please explain: ______

______

5a. Amount of award received: ______

5b. When did you receive the award? ______

5c. Was the award educational? yes ___ no ___

5d. Did the award include room and board? yes ___ no ___ tuition? yes ___ no ___

5e. If the award was educational, submit official transcript of vocational school or college records.

5f. Do you have credits earned toward degree requirements? (If applicable attach documents)

6. Executive Summary (summarize the proposal in 150 words or less)

7. Grant amount requested: ______

Attach statement answers to the following five (5) questions.

Please limit the length of your answers to no more than a total of four (4) pages.

1. Is goal self-improving? yes ____ no ____ Service to the community? yes ___ no ___

2. What actions have been taken in pursuit of this goal? (attach statement)

3. What are your educational goals?

3a. What point are you at in achieving those educational goals?

4. What are your career goals?

5. How will your goal/proposal effect or enrich Washington State, the Greater Puget Sound Area or the Community?

No Funding will be awarded to the same Individual in consecutive funding cycles.

ATTACHMENTS

1.Attach work resume.

2. Give pertinent information concerning your earnings or other financial assets and obligations that may be helpful in assessing your financial need. (Attach statement and data)

Funds are to be used only for the purpose of the grant.

NOTE:

The Foundation will not accept faxed applications.

All Grant Applications must be mailed via the United States Postal Service,

in regular mail, no “return receipt requested”.

(Additional information may be requested)

Recipient will provide a notarized report to the foundation every 60 days providing information as to fund disbursement, accompanied by proof of same in the form of paid invoices, checks written, and any other form of disbursement for the purpose of completing the grant. In the case of funds used for educational purposes all grade information reports will provided, including any correspondence from teaching authorities.

A final disbursement report will be provided to the Foundation no later than 45 days after completion of the grant.

Only one grant application may be filed per calendar year by any individual. The calendar year is defined as January 1st through December 31st.

No Funding will be awarded to the same Individual in consecutive funding cycles.

The Garneau-Nicon Family Foundation reserves the right to withhold, withdraw, and or recover funds in such cases where funds are, or appear to be misused.

I certify that all of the facts contained herein or attached are true and correct.

______

Date Signature of Applicant

Return Application to Garneau-Nicon Family Foundation

10009 Aurora North, Seattle, WA 98133

5-19-17