GRANT APPLICATION

THE HARRY E. AND OLIVE T. BARTH CHARITABLE TRUST

PURPOSE: For use by non-profit organizations in West Virginia with preference, though not exclusively, to those organizations from the City of Sistersville, West Virginia and Tyler County, West Virginia areas that are seeking grants for program support within the guidelines established in the Trust Indenture.

INSTRUCTION: Applicants are encouraged to submit only this form for consideration. Applications must be typed. Complete each section of the application in the space provided and be as concise as possible. NOTE: Applications without a contact name or Tax ID Number will not be reviewed.

Grant applications are due by 5:00 pm September 22, 2017.Upon completion, you may mail your Application Form to The Harry E. and Olive T. Barth Charitable Trust, c/o Community Foundation for the Ohio Valley (CFOV), 1310 Market Street, Wheeling, WV 26003. Questions regarding this application or grant program, can be directed to CFOV at (304) 242-3144 or email: .

FORM FOR MAKING APPLICATION TO

THE HARRY E. AND OLIVE T. BARTH CHARITABLE TRUST

Legal name and mailing address of civic or non-profit organization submitting application as listed with the West Virginia Secretary of State:

______

______

______

Tax Exempt ID Number: ______

Location where project will take place: ______

Contact Information:

Name:______

Phone:______Fax: ______

E-Mail:______

Other charity involved with project, if any: ______

1.TOTAL PROJECT COST: $______

2.AMOUNT REQUESTED FROM BARTH CHARITABLE TRUST: $______

3.SPECIFIC PURPOSE FOR WHICH FUNDS ARE BEING SOUGHT (Please reference the Guidelines established under the Trust Indenture for which grants may be made attached hereto):

4.INTRODUCTION – Give a brief description of the organization seeking funds:

5.PROBLEMS, OBJECTIVES, METHODS – Give a brief description of the basic need; describe what it is you want to accomplish and methods you plan to use:

6.TIMING – List the date(s) or timeframe for the project. Give its current status, indicating how long it will take to finish and whether there are later stages:

7.COST AND FINANCING - List the principal cost elements of the project.

What funds have already been obtained? List sources, including other foundations. How much has been raised locally or from your own constituency?

When will this project be self-supporting?

8.EVALUATION – Explain how you are going to determine that you have accomplished what you want to do.

9.a.FINANCIAL INFORMATION – Please attach one copy of your most recent financial statement or balance sheet (audited, if available).

b.IRS FORM 990 – Please include your most recently submitted return (if applicable).

c.DETERMINATION LETTER – Please provide a copy of the most recent Determination Letter issued by the IRS District Director (if applicable).

d.PUBLIC ENTITY STATUS – (i.e. county, municipality or subdivision thereof) (if applicable).

I/we hereby certify that the information provided on this application form is true and accurate to the best of my knowledge and belief.

______

Signature of ApplicantTitleDate

Please Do Not Write Below Your Signature

ADVISORY COMMITTEE NOTES:

ACTION TAKEN BY ADVISORY COMMITTEE:

APPROVED:DATE:______AMOUNT:______

NOT APPROVED:DATE:______FOLLOW UP BY:______

ACTION TAKEN BY COMMUNITY FOUNDATION FOR THE OHIO VALLEY, INC.:

APPROVED:DATE:______AMOUNT:______

NOT APPROVED:DATE:______

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