Please complete this Application in its entirety. Answers to all of the questions are essential to our Board of Directors’ decision-making process. Unanswered questions may delay the review of your grant request. Please type or print clearly. Please enable JavaScript in your browser to complete this form.Date Of Application:Organization Name: *Street Address/PO Box: *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact Name: *Title:Phone:Tax (EIN): *Please attach the following documents to the grant application:Current Operating BudgetCurrent Audited Financial StatementAnnual ReportFederal Tax Return (990)Copy of the current IRS Determination Letter 501©(3) Tax Exempt StatusCurrent IRS Form W-9List of Officers and Board MembersLetters of support (optional) that substantiate need for campaign and collaboration with other organizations.List of current financial resources: (a) Name of financial institution/brokerage, (b) Type of account (i.e. checking, money market, CD, other investments (c) Dollar Amount (d) Current debt, type of loan and amount.File Upload Click or drag files to this area to upload. You can upload up to 9 files. Dollar Amount of Grant Request: *Type of Grant Request (check all that apply): *CapitalChallenge GrantMatching GrantProject SupportTechnologyOther (please specify):Grant Request Type: *Please provide an estimate of the total cost of the Program/Project for which you are applying: Date your Organization was founded:Provide a brief description of your Organization (You may include literature, brochures, etc., if applicable.)Briefly describe the Program/Project for which you are requesting grant moneys and indicate how the money from this grant request will be spent.What is the projected time line for implementation of this Program/Project? If you are unable to meet your financial goal, will the project continue?List the proposal’s target population/constituents/socio-economic status and geographic communities.(For example: 75 Infants of families with low to moderate income in center city Allentown, 200 Senior Citizens in Northampton County with mid to low income, serves 200 abused Children in Easton - 50% of the children are from families with low to moderate incomes)Please list the names of foundations, corporations and other sources that you are soliciting for funding and the status of your proposal with each including the amount of contribution received or pending:Signature:Date:Thank you for your interest in the Keystone Savings Foundation and for taking the time to submit this grant request.Submit Let's Help our community together! Contact Us
