The Blowitz-Ridgeway Foundation
SHORT FORM Application Page 1
THE BLOWITZ-RIDGEWAY FOUNDATION
SHORT FORM GRANT APPLICATION
***NOTE: THIS “SHORT FORM APPLICATION IS TO BE USED ONLY FOR GRANT REQUESTS OF $15,000 OR LESS. PLEASE CONTACT THE FOUNDATION TO RECEIVE THE PROPER FORM FOR REQUESTS GREATER THAN $15,000***
PLEASE RETURN A TOTAL OF FIVE COPIES OF THIS APPLICATION AND FIVE COPIES OF ALL ATTACHMENTS
Summary answers to each question MUST APPEAR. “Please see attached” is NOT ACCEPTABLE. This application can be duplicated on your computer in order to provide adequate space for your response. Attachments may be used only to supplement summary answers.
1. Exact name of applicant organization:
2. Address of applicant:
3. Name, address, telephone number and email of the person administering the grant applied for:
4.Please state the organization’s purpose:
5. Has the applicant organization or members of its Board of Directors previously applied for or received a grant from the Blowitz-Ridgeway Foundation? If yes, please explain.
6.Give the amount and full details of the purpose of the grant currently applied for. Please include the time period covered by the grant request, if applicable, listing month and year of your fiscal year (NOTE: The time period must be for a future date, as it still may take 2-4 months before your application is reviewed).
7.Please describe the population served by this grant and agency including: income-level, geographic area, and age group:
8. Please state the measurable objectives and goals that your program anticipates accomplishing by the end of
the grant funding year. [Note that periodic status reports will be requested asking you to report on the progress made towards achieving these objectives and goals.]
9.Please list all other funding sources for this request. Include all amounts and indicate whether received, committed, or applied/pending.
Grant SourceAmount RequestedAppl. DateStatus
10.What are the total administrative costs for your agency?
11.If you seek a one year grant for a multiple year program or project, what funding sources do you anticipate
using in the future?
12.What collaborations has your organization been involved in during the past two years?
13.Please submit copies of the following documents, and indicate their inclusion in your application by
placinga corresponding Exhibit Number (to reference the documents) in space provided:
EXHIBIT #:
______a.) Latest full-year audited financial statements. (Organizations with revenues of
less than $300,000 may submit their 990 federal tax form and unaudited financial statements. However, a 990-N is not acceptable.)
______b.) A current budget for your agency.
______c.) A current budget for the specific program or project for which you seek funding.
______d.) A copy of your most recent IRS determination letter(s) relating to 501(c) (3)
and private foundation status.
______e.)A copy of your most recent Schedule A from Form 990.
The undersigned hereby certifies that all of the foregoing information and attachments, when submitted, will be correct to the best of his/her information and belief.
DATE: ______
(Signature)
______
(Name-type or print)(Title)
**PLEASE NOTE: Omission of any of the required exhibits will delay consideration of the application.**
Rev. January, 2015