Contact 1 — 100 Thousand Foundation

Grant Application

Organization Name

CONTACT INFORMATION

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Website

http://

Primary Contact

First Name

Last Name

ORGANIZATION DETAILS

Year Founded

Federal EIN

Total Operating Revenue for the last full fiscal year

Grant Project or Program Title

Please specify the type of program (new, existing, expansion, etc.)

Total grant project or program budgeted amount

If you do not have an exact amount, please provide an estimate

Mission Statement + Project/Program Details

Describe in a few sentences the project or program(s) for which you request the $100,000 funding. Propose a new project or program or expansion or continued support of an existing, proven project or program that will have a transformative effect on the organization and the community it serves.

Describe how this grant project would significantly impact the organization and the people/communities served.

Acknowledgement

Please check and confirm the following statements.

I acknowledge all grant funds must be used within 24 months.

I confirm I have grant application approval from our Executive Director.

I certify that this organization is an IRS 501(c)(3) organization and our tax- exempt status has not been revoked or modified. I certify that I have reviewed this application along with the 100 Thousand eligibility guidelines prior to submission, and the information provided in the application is accurate and verifiable.

Name

Please enter the name of the person submitting this form.

First Name

Last Name