<p>Grant Application GENERAL AGENCY INFORMATION Date of Application: EIN#:</p><p>Name of Organization:</p><p>Mailing Address:</p><p>Physical Address:</p><p>Phone #: Fax#:</p><p>Website: Organization Email:</p><p>Executive Director:</p><p>Executive Director’s Phone: Email:</p><p>Organization’s Mission:</p><p>Annual Organization Budget:</p><p>Organization Interest Area (Check all that apply):</p><p>Animal Welfare Arts/Culture Civic Engagement Community Development</p><p>Education Employment Environment Health</p><p>Housing/Homelessness Human Services Philanthropy/Volunteer Public Protection</p><p>Recreation Religion Technology Youth Development</p><p>Geographic Locations Served (Check all that apply):</p><p>Calhoun Clarendon Fairfield Kershaw Lee Lexington </p><p>Newberry Orangeburg Richland Saluda Sumter </p><p>Population Served (Check all that apply): Race/Ethnicity Gender Age Groups</p><p>African American/Black Young Children (0 – 5)</p><p>Asian or Pacific Islander Children (6 – 12)</p><p>Hispanic/Latino Female Male Youth (13 – 18)</p><p>Caucasian/White Adults (19 – 64)</p><p>Other Seniors (65+)</p><p>PROJECT INFORMATION Type of Grant Requested: Community Impact Organizational Impact</p><p>Focus Area: Dropout Prevention Illiteracy Reduction Project Contact Person/Title: (if other than Executive Director) Contact Person’s Phone #: Email:</p><p>Project Title:</p><p>Project Description:</p><p>Project Timetable:</p><p>Geographic Locations Served (Check all that apply):</p><p>Calhoun Clarendon Fairfield Kershaw Lee Lexington</p><p>Newberry Orangeburg Richland Saluda Sumter</p><p>Population Served (Check all that apply): Race/Ethnicity Gender Age Groups</p><p>African American/Black Young Children (0 – 5)</p><p>Asian or Pacific Islander Children (6 – 12)</p><p>Hispanic/Latino Female Male Youth (13 – 18)</p><p>Caucasian/White Adults (19 – 64)</p><p>Other Seniors (65+)</p><p>Amount Requested: Total Project Budget:</p><p>Board Chair (Please Type/Print) Executive Director (Please Type/Print)</p><p>Board Chair Signature Date Executive Director Signature Date Grant Checklist</p><p>Please check the items that are true for your organization.</p><p>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]. </p><p>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.</p><p>Our organization has: An Internal Revenue Service 501(c)(3) tax exemption letter.</p><p>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.</p><p>Operating by-laws and articles of incorporation.</p><p>A vision, values and mission statement.</p><p>Copies of Board of Trustee meeting minutes over the last 12 months.</p><p>Copies of the most recent financial documents:</p><p>Audited Financial Statements Reviewed Financial Statements</p><p>Compiled Financial Statements IRS Form 990</p><p>A current strategic plan.</p><p>A current annual report.</p><p>An organizational chart.</p><p>A conflict of interest policy.</p><p>A whistleblower policy.</p><p>Name & Title (print)</p><p>Organization </p><p>Signature Date </p>