Heron Creek Community Foundation

2017GRANT Application

ORGANIZATION Information
Organization Name:
Contact Person: / Phone: / Cell Phone:
Organizationaddress:
Mission of your Organization:
GRANT DESCRIPTION
Amount Requested:
Description of proposed use of this grant request:
Total Cost of Project if grant request will not cover total:
How many North Port residents do you realistically estimate will be helped by this grant:
Explain above answer:
If requested HCCF grant would not cover total, how do you expect to pay for the remaining cost:
How do you measure the success of the program or project for which this grant is requested:
Date and amount of any previous HCCF grants received:
Name of any other source to which you have applied for this same project: Include name of source and when you expect notification of award or denial.
MATCHING FUNDS
Is your organization eligible to receive matching funds for this grant:
If so, what is the source of matching funds (Must attach a Letter of Intent from the donor):

Heron Creek Community Foundation

GRANT Application Page 2

ORGANIZATION DETAILS
Estimated number of people served by your organization in past year:
Name any other organizations in the area providing similar services:
Usual source of funds to operate your organization:
Government ______%
Charitable Foundations ______%
Contributions ______%
Other ______%
Explain:
CLIENTele Information
From what sources does your organization receive its client referrals:
What are the needs requirements for receiving assistance from your organization:
How will your organization screen potential clients in order to ensure HCCF grant funds go only to those who are in need and cannot otherwise pay for services:
CHECKLIST OF ADDITIONAL DOCUMENTS REQUIRED
Name of Document / Check if Attached
List of Names on Board of Directors and Trustees including term on Board
Copy of IRS 501(c)(3) Tax-Exempt Letter of Determination (not EIN or FL State Sales Tax Exemption)
Budget of requested grant from HCCF
For grant requests of $3,000 or more,
CPA prepared Balance Sheet (most recent fiscal year)
Income Statement (most recent fiscal year)
For grant requests of less than $3,000,
Internally prepared financial statements
Letter of Intent from any matching donor
Signature
I authorize Heron Creek Community Foundationto verify the information provided on this form as to my credit and organization history.
Signature of applicant representative / Date

Grant Application.docx