APPLICATION FOR GRANT

 

         

Section One: Basic Information

           

          Date of application:_____________Amount requested: $__________________

 

          Application submitted to: Albert E. and Birdie W. Einstein Fund, Inc.

 

          Name of Organization:_______________________________________

 

          Address:_________________________________________________

 

          City___________State_____________Zip Code__________________________

 

          Website__________________________________________________

 

Mission of your organization:_______________________________________

______________________________________________________________________

________________________________________________________

________________________________________________________

 

 

         

            Year organization founded:___________Navigator Rating____________

 

          Total number of Officers and Directors________________________________

            Aggregate  Compensation:___________________________________________

           

           Number Full time Employees:_______Number Part- time employees______

Aggregate  Compensation:___________________________________________

    

Title__________________Address:____________________________________

 

Phone:__________Fax:_____________E-Mail___________________________

 

Top Official_______________________________________________________

 

Title:_____________________Address:________________________________

 

Phone:________________Fax:________________E-Mail:_________________

 

 

     

   

  

 

 

  

 

 

Section Two: Proposal Information

 

Amount of Grant Request:_______________________________________________

 

GOALS/INTENDED USE OF FUNDS: - What is the problem or issue to be addressed through the use of these Funds?  What do you expect to accomplish?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

TARGET POPULATION: Who will be served through the use of these funds?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

OTHER FUNDING SOURCES:-Do you have other funding sources (over $1,000 each) for this project?  List

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

LITIGATION- Is there any pending litigation against your organization? Yes_____

NO___ If Yes, please explain:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Has your organization had to pay any court ordered judgments in the past three years? If so, for what and how much?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

OTHER USEFUL INFORMATION: - Is there anything else a potential funder should consider in reviewing this proposal? Do you have fund raising events?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

REQUESTED ATTACHMENTS:

 

A.                IRS Letter of Determination

B.                 Most recent Form 990 (including Schedule A)

C.                Financial statement (Audited, if available)

D.                List of board members

E.                 Current Corporate Resolutions

 

 

  

  

  

  

 

Section Three: Certification

 

As a Florida nonprofit organization, you are required to register with the State as a charity.  Please provide a copy of your registration letter.

 

In addition, the top official of your organization as well as the chairperson for your governing board must sign the following statement:

 

1.                  Submission of this funding proposal is authorized by our

Organizationís Board of Directors.

 

2.                  Tax exemption under IRS Section 501(c ) (3) for_________________

__________________________________________________________

                                    Name of organization

 

             has not been revoked or modified.

 3.                  The applicant organization understands that should the requested grants be made, the applicant organization will furnish a report

indicating how funds were spent and that the funds were spent solely for the purposes for which the grant is sought.  The applicant organization understands that it will be expected to accept the terms and conditions set out by the grant maker.

 

We certify that to the best of our knowledge, the statements contained in this application are true, correct and complete.

 

Top Official:                                                              Board Chairperson

 

_________________________                                  ______________________________

Print Name                                                                Print Name

 

_________________________                                  ______________________________

Title                                                                            Title

 

_________________________                                  _____________________________

Signature                    Date                                        Signature                                Date

 

 

Send to: Albert E. & Birdie W. Einstein Fund;

PO Box 372279 Satellite Beach Florida 32937
Please do not send applications by Registered or Certified mail