THE SEYMOUR Fox MEMORIAL FOUNDATION, INC

THE SEYMOUR Fox MEMORIAL FOUNDATION, INC.

Grant Application

A. General Information:

Date of application: ___________________________

Name of applicant. (Please list exact legal name):

______________________________________________________________________________

Address of organization __________________________________________________________

Telephone number: __________ Fax: ___________email:__________________________

Purpose of grant _______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Project name (if applicable): ______________________________________________________

Executive director: ______________________________________________________________________________

Contact person and title (if not executive director): _________________________________________________________

Is your organization a 501 (c)(3) tax exempt organization? (yes or no):

If no, please explain organization’s status: ______________________________________________________________________________

Please attach a copy of letter granting tax exempt status issued by the IRS.

Grant request: $ ________________________________

Total project budget $ ____________________

Dates covered by project budget (mo/day/year): ________________________

B. Funding Request

Please provide a narrative, preferably in 2 pages or less, describing the program for which you seek funding, including:

A statement of its primary purpose and the need or problem that you are seeking to address.

The population that you plan to serve and how this population will benefit from the project.

Strategies that you will employ to implement your project.

The names and titles of the individuals who will direct the project

Anticipated length of the project.

How the project contributes to your organization's overall mission.

How you plan to use any funds awarded.

C. Evaluation—

Please explain how you will measure the effectiveness of your activities. Describe your criteria for a successful program and the results you expect to have achieved by the end of the project.

D. Attachments: Please label all attachments to correspond to the bold-faced, capitalized items below.

Financial Information—Please provide the dates that each document covers.

1. Your MOST RECENT FINANCIAL STATEMENT, audited if available. This statement should reflect actual expenditures and funds received during your most recent fiscal year.

2. OPERATING EXPENSE BUDGETS for the current and most recent fiscal year.

3. A LIST OF foundation and corporate SUPPORTERS and all other sources of income, with amounts, for your current fiscal year.

4. A CURRENT BUDGET FOR THE PROJECT. Indicate the specific uses of the requested grant.

5. A list of all sources of CURRENT OR FUTURE INCOME, if any, anticipated from the project.

6. A copy of your FORM 990 for your most recent tax year.

E. Other Supporting Materials

1. A list of your Board of Directors and their affiliations.

2. Names and resumes of key staff members related to the project.

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