Grant Request Form - Ballantine Family Fund Grants Manager

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Grant Requests Details

Total Amount Requested

The maximum amount of this grant is $5,000.00.

Request Profile

Title of Request ex. Uniforms for Marching Band, Acme General Operations

Primary County of Service or County Location of Main Office

Executive Summary

0 / 1500

A brief overview of the grant request, community need, and desired outcome. Please include the dollar amount requested and whether the grant will be applied toward programs or operations.

Background

Briefly describe your organization, its history, purpose and recent accomplishments.

Status

What is your nonprofit's tax exempt status?

Nonprofit EIN

Fiscal Sponsor Information

Fiscal Sponsor's Organization Name

Fiscal Sponsor's Tax Id

Please upload a letter, dated within one year, from your fiscal sponsor specifying that your nonprofit has authorization to use their IRS letter. The organization should also stipulate that it will act as a fiscal agent and take responsibility to ensure that funds are expended for charitable purposes.
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Mailing Address

Mailing Address 2

City

State

Zip

Leadership

Has your board of directors met regularly over the past 12 months?

Does every board member make a financial contribution to your organization?

Please upload a list of your current board members. Please include name, board position and contact information (email/phone).
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Financials

If you are using a fiscal sponsor, share financials for your project; do not share your fiscal sponsor’s financials.

Budgeted gross income for current year

Actual gross income for previous year

Were your budget goals achieved for the previous year?

Please explain why the budget was not accomplished

Net income for previous year (actual gross income minus expenses = net income)

Please review the financial statements being attached below. The numbers entered above must match the numbers in the attachments provided. If the numbers do not match, please provide an explanation. For example, do you have a multi-year gift or restricted income that requires clarification? Explanation of financials (if needed)

Current annual budget for this year
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Current annual budget with year-to-date actuals
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Budget vs actuals for previous fiscal year
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Current balance sheet (from the most recent month end)
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Operations Info

List the two most recent grants your organization has received, including grantor and amount of grant.

Grant ONE Please keep this response to around 20 words.

Grant TWO Please keep this response to around 20 words.

I certify the information entered is accurate to the best of my knowledge.