2023 Grant Application Form

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Before printing your application please make sure you have expanded all text boxes to ensure the Board can fully read your application.

I have read and acknowledge all guidelines for this application process *

Yes

Organization's Name *

Mailing Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Fax

Email Address *

Organization Website *

Mission of the Organization: *

Services provided by your Organization (list all services that represent five percent or more of your budget): *

Areas of Charitable Service (check all that apply): *

Region served by Organization (check all that apply) *

Year organization established: *

Year received tax-exempt status *

Number of Employees *

Budget for most recent year-end *

Name of accounting firm that handles audit and review of funds *

Contact Name *

Contact Phone *

May the Foundation contact the accounting firm for additional information? *

Yes

No

Type Of Grant Requested

The Applicant requests a grant to be applied toward a specific project in the following amount *

Project Description

Describe your project. Please include: (i) the purpose and goals of your project; (ii) the statement of need for your project; (iii) the class of individuals served by the project and the location of those individuals; and (iv) the way in which you will measure the success of your project. *

Project Plan

Describe the implementation process for your project. Be sure to include information on key staff and volunteer project managers. *

Evaluation Process

Describe the evaluation process for your project including expected outcomes. Please outline: (i) the evaluation process; and (ii) a description of how the project will be funded in future years. *

Budget Information

Applicant year-end *

Amount requested *

Time period for payment *

Budget Detail (These are example templates. Please provide your actual Project Budget and Organization Budget as one of the required attachments.)

	Budget For Project	Annual Budget for Organization
Salaries	Budget For Project	Annual Budget for Organization
Payroll Taxes	Budget For Project	Annual Budget for Organization
Fringe Benefits	Budget For Project	Annual Budget for Organization
General Overhead	Budget For Project	Annual Budget for Organization
Travel	Budget For Project	Annual Budget for Organization
Consultants / Professional Fees	Budget For Project	Annual Budget for Organization
Postage	Budget For Project	Annual Budget for Organization
Office Supplies	Budget For Project	Annual Budget for Organization
Marketing / Communications	Budget For Project	Annual Budget for Organization
Capital Expenditures	Budget For Project	Annual Budget for Organization

Total Budget for Project *

Total Annual Budget for Organization *

Revenue Detail

	Budget For Project	Annual Budget for Organization
Individual Contributions	Budget For Project	Annual Budget for Organization
Corporate Contributions	Budget For Project	Annual Budget for Organization
Foundation Grants	Budget For Project	Annual Budget for Organization
Government Grants	Budget For Project	Annual Budget for Organization
Membership Income	Budget For Project	Annual Budget for Organization
Special Events	Budget For Project	Annual Budget for Organization
In-Kind Support	Budget For Project	Annual Budget for Organization
Other (specify)	Budget For Project	Annual Budget for Organization
Office Supplies	Budget For Project	Annual Budget for Organization

Total Revenue for Project *

Total Annual Revenue for Organization *

List all other foundations that have been asked to fund this project, the amounts requested, and the current status.

	Amount Requested	Status
Foundation	Amount Requested	Status
Foundation	Amount Requested	Status
Foundation	Amount Requested	Status
Foundation	Amount Requested	Status

Attachments Required - Please print and include in your mailed-in application.

IRS tax determination letter showing that you are recognized public charity and that you are not a private foundation.

Affidavit from a representative of your organization stating that the IRS has not revoked your tax-exempt status or changed its status since the issuance of the tax determination letter.

A copy of the organization's most recent annual report, if available.

A copy of the most recent audited financial statement of your organization.

A list of the organization's board of directors or trustees, showing name, corporate title, volunteer title, address, and telephone number.

A copy of the most recently filed 990 Non-Profit tax return.

Organization Budget

Project Budget

Statement from Applicant Organization’s Chief Executive Office and Chief Volunteer Officer:

We do herby certify that the information provided in this Grant Application is accurate and complete to the best of our ability and knowledge. We further acknowledge that if awarded a grant from the Carrico Family Foundation, we will provide certification to the Carrico Family Foundation that the funds have been used for the purposes for which the grant was awarded. We will make this certification within the time specified by the Grant Agreement.

Chief Executive Officer of Applicant Signature

clear

Printed name and title *

Date * +

Chief Volunteer Officer of Applicant Signature

clear

Printed name and title *

Date * +

We do not accept electronic application submissions. After submitting this form you will receive an email of your completed answers. Please print that email and supporting documents and mail to:

Carrico Family Foundation
PO Box 4436
Medford, OR 97501

Before printing your application please make sure you have expanded all text boxes to ensure the Board can fully read your application.

Arts	Education	Developmentally Disabled / Handicapped
Health Care	Social / Human Services	Youth Organization
Religious	Environmental	Community Improvement
Other Other

Medford	Talent	Ashland
Phoenix	Jackson County	Josephine County
Upper Rogue	Lower Rogue	Other Other