GENERAL AGENCY Information

Grant Application GENERAL AGENCY INFORMATION Date of Application: EIN#:

Name of Organization:

Mailing Address:

Physical Address:

Phone #: Fax#:

Website: Organization Email:

Executive Director:

Executive Director’s Phone: Email:

Organization’s Mission:

Annual Organization Budget:

Organization Interest Area (Check all that apply):

Animal Welfare Arts/Culture Civic Engagement Community Development

Education Employment Environment Health

Housing/Homelessness Human Services Philanthropy/Volunteer Public Protection

Recreation Religion Technology Youth Development

Geographic Locations Served (Check all that apply):

Calhoun Clarendon Fairfield Kershaw Lee Lexington

Newberry Orangeburg Richland Saluda Sumter

Population Served (Check all that apply): Race/Ethnicity Gender Age Groups

African American/Black Young Children (0 – 5)

Asian or Pacific Islander Children (6 – 12)

Hispanic/Latino Female Male Youth (13 – 18)

Caucasian/White Adults (19 – 64)

Other Seniors (65+)

PROJECT INFORMATION Type of Grant Requested: Community Impact Organizational Impact

Focus Area: Dropout Prevention Illiteracy Reduction Project Contact Person/Title: (if other than Executive Director) Contact Person’s Phone #: Email:

Project Title:

Project Description:

Project Timetable:

Geographic Locations Served (Check all that apply):

Calhoun Clarendon Fairfield Kershaw Lee Lexington

Newberry Orangeburg Richland Saluda Sumter

Population Served (Check all that apply): Race/Ethnicity Gender Age Groups

African American/Black Young Children (0 – 5)

Asian or Pacific Islander Children (6 – 12)

Hispanic/Latino Female Male Youth (13 – 18)

Caucasian/White Adults (19 – 64)

Other Seniors (65+)

Amount Requested: Total Project Budget:

Board Chair (Please Type/Print) Executive Director (Please Type/Print)

Board Chair Signature Date Executive Director Signature Date Grant Checklist

Please check the items that are true for your organization.

The following information will be helpful to the Program & Grantmaking Committee when reviewing the grant proposals for each cycle. Sign and attach the completed form to your proposal. If you have any questions please contact our office at 803-254-5601 or email [email protected].

Please DO NOT send the items as attachments. However, please be prepared to provide proper documentation of this information to the Program & Grantmaking Committee upon request.

Our organization has: An Internal Revenue Service 501(c)(3) tax exemption letter.

A charitable registration letter from the South Carolina Secretary of State's Public Charities Section or a current letter stating that our organization is exempt from registration.

Operating by-laws and articles of incorporation.

A vision, values and mission statement.

Copies of Board of Trustee meeting minutes over the last 12 months.

Copies of the most recent financial documents:

Audited Financial Statements Reviewed Financial Statements

Compiled Financial Statements IRS Form 990

A current strategic plan.

A current annual report.

An organizational chart.

A conflict of interest policy.

A whistleblower policy.

Name & Title (print)

Organization

Signature Date