SAMPLE 2012 Online Grant Application
This is a sample grant application and will not be accepted for consideration for a grant request.
All grant applications must be submitted online.
Please visit our website find out more about PG&E’s Community Investment Program and how to apply for a grant.
Organization Information
Are you a Fiscal Sponsor? Yes or No
If YES, please answer all of the questions in this application as they relate to your organization, not the organization you are sponsoring for this grant.
Federal Tax ID
Organization Official Name -This should be your Official Legal Name as it is currently listed with the IRS.
Also Known As -If your organization has a different name than is listed above, enter it here. (Optional)
Organization Address -This address is where all correspondence will be mailed.
AddressCityStateZip Code
Organization Location(City/County) - Select from the list the best match to your organization's physical location.
Organization Main PhoneOrganization Main FaxOrganization Website
Organization Executive Director - If you are a national nonprofit, please list your local chapter’s Executive Director.
PrefixFirst Name Last Name
PG&E Primary Staff Contact - You must select the name of your PGE Contact from the list provided. If you don’t know your PG&E contact, please refer to our website for a list of regional contacts.
PG&E Staff – Additional -If you have discussed this proposal with any additional PG&E employees not listed above, please enter their names here (Optional)
Board of Directors -Please list the names of any PG&E employees who currently serve on your Board of Directors (Optional)
Contact Information
Organization Contact
PrefixFirst Name Last Name
Title in OrganizationDirect PhoneEmail
___Check this box if the Request Contact is the same as the Organization Contact listed above
Request Contact
PrefixFirst Name Last Name
Title in Organization Direct Phone Email
Proposal Information
Request
Request Date - This will be automatically filled by the system.
Request Amount $
Grant Description Title-This should be the descriptive title or name of your project. If you are a Fiscal Sponsor, please include the name of the non-exempt organization you are sponsoring in the title.
Project Description- This should be the detailed description of the project or program for which you are requesting funding.
Focus Area - Select from the list provided the choice that best describes the focus of your proposal.
In what county or area will this grant primarily be used? - Please select the county where the MAJORITY of the funds will be used. If you are requesting funding for a project that is regionally-based or will impact multiple counties, you may select up to three counties to represent the area covered. If your project is statewide or outside of California, please select the choice that best represents where the funds will be used.
How will PG&E be recognized for this donation throughout the upcoming year? - Please give specific examples such as:public recognition on website, newsletters, media advisories, event signage etc.
Funds Distribution
Please provide a dollar amount for each applicable category below.
Project or Program Amount$
General Operating Amount $
Capital Amount$
Event Amount $
Statistical Information
In order to benchmark and illustrate PG&E's commitment to community investments, we ask that you please answer the following questions specific to this grant request.
Please note this data is used for statistical purposes only and it does not affect the grant approval process.
Primary Target Population (Select One)
Disabled / Homeless / LGBT / Seniors / Veterans / Women & Girls (all ages)
Age Group Target Population(Select Up To Three)
(You may select up to three if your target population includes more than one age group of children.)
Infants (0-5) / Children (6-13) / Youth (14-18) / Adults (19-55) / Seniors (55+) / All (General Audience)
Gender of Target Population (Select One)Female (only) / Male (only) / All (General Audience)
Will at least half of the requested grant amount be used to benefit an Underserved Population?
Yes or No
Will at least half of therequested grant amount be used to benefit Low Income Households?
Yes or No
Please provide a dollar amount for each applicable category below as it relates to this grant request. (Please enter zero (0) where non-applicable. The total does not need to equal the full grant amount requested.)
African-American $
Asian-American (includes Pacific Islander) $
Latin-American (Hispanic)$
Native-American$
Do the majority of your Board of Directors identify as a member of a minority? Minority in this context is defined as someone who identifies as a member of any ethnic group other than Caucasian, and/or women, LGBT or disabled. Majority is defined as more than 50%. Yes or No
Compliance and Certification
Please read this section thoroughly and confirm that your organization is in compliance with the following terms and conditions. Please note that disagreeing to any statement will disqualify you for a charitable donation.
Compliance Disclosures
The applicant is, and shall remain, in compliance with all federal, state, and local laws, rules, and regulations, including if applicable the California Nonprofit Integrity Act of 2004.
The applicant does not and shall not, in its by-laws, policies, or practices, discriminate on the basis of race, color, religion, age, sex, national origin, ancestry, physical or mental disability, medical condition, veteran status, marital status, pregnancy, sexual orientation, gender identity, or any basis prohibited by applicable law.
The applicant agrees that any donation from PG&E will be used only for charitable purposes, and will not be used to promote or oppose any candidate or ballot measure, to advocate any legislative or administrative action, or to personally benefit or compensate any elected official.
The applicant and each of its grantees, if any, is in full compliance with all statutes, Executive Orders, and regulations restricting or prohibiting U.S. persons from engaging in transactions and dealings with countries, entities, or individuals subject to economic sanctions administered by the U.S. Department of the Treasury's Office of Foreign Assets Control, the applicant is aware that a list of countries subject to such sanctions, a list of Specially Designated Nationals and Blocked Persons subject to such sanctions, and overviews and guidelines for each such sanctions program can be found at and the applicant does not and shall not promote or engage in violence, terrorism, bigotry, or the destruction of any state, or make grants or otherwise furnish support of any kind to any individual or entity that engages in such activities. Should any change in circumstances pertaining to this certification occur at any time, the applicant will notify the Community Relations Department of Pacific Gas and Electric Company immediately.
I certify that the above four statements are true to the best of my knowledge.
Agree___ Disagree ___
Certification
I am the duly appointed representative of my organization. I'm authorized to certify and affirm all the statements above, and to submit the application on behalf of my organization.
I have read all the statements and responses in this application, and certify that each is accurate.
I agree that electronic submission of this application will be deemed to be the equivalent of my written signature for purposes of this certification and application.
By accepting any funds or in-kind donations from PG&E, my organization agrees to all terms, conditions and certifications specified within the application and the transmittal letter.
My name is:
My position title with this organization is:
Signed by (enter name)Signed on this date
Attachment Instructions
NEW for 2012 we require a current W-9 be attached to your application.
The W-9 form must be SIGNED and DATED to be accepted.
Make sure your W-9 is:
1. Signed by an official of the organization.
2. Dated no more than 5 months from the submission date of this application.
3. A match to what is on file with the IRS.
NEED A FORM? Download the newest W-9 form from the IRS by clicking here.
Please follow these 4 steps to complete your W-9 form:
1. Download a copy of the form.
2. Fill out the entire form
3. Print your completed form and sign and date it.
4. Scan the signed completed form and attach the file to your application.
*If you do not have a scanner, please fax your completed form to your PG&E contact who will then scan it and email it back to you for attaching to your application.
If you have recently changed your physical or mailing address and have not updated it with the IRS, do not enter it on the W-9, but update it on the Organization Information section at the beginning of this application.
SAMPLE 2012 PGE&E ONLINE GRANT APPLICATION Page 1