Grant Application

Grant Application for organizations seeking funds from the Foundation are required to suppy information requested below and forward to the Foundation office.
1. IRS Tax Exemption Letter or Number (if available)
2. List of Board of Directors
3. Current Operating Budget (Income & Expenses)
4. Latest Financial Statement
5. Original and 5 copies of this application

Before beginning, please read through all the instructions, click here.
(Failure to follow these instructions may result in your application being disqualified.)  Please limit your responses to no more than 75 words for each question.

Applicant:
Organization:
Date:
Address:
City, State, Zip:

Contact Person:
Telephone:
Address:

Project Title and Description:

Amount requested from Merrick Foundation, Inc. $
Anticipated Total Cost of the Project $
Funding Period: From To
Sources of Other Funds (Commitments to date, applications, matching funds-in cash/in kind, etc.):



Budget for the Project:

Purpose: 
What will the project accomplish? What benefits will it provide? What community need does this request meet?

Your type of organization, and the needs that you meet, primarily fit which of the following classification(s)?
Civic	Cultural	Health	Welfare	Educational

Other Academic Activities Not Listed:

Implementation: 
How will this project be accomplished? (Who, what, when, etc.?)

Additional Funds : 
How do you propose to raise the other funds necessary for this project? Would a grant from the Foundation qualify as a matching fund from any other funding source?

Does this project require volunteerism? 
What type? How many hours? Provided by whom? Can it be documented?

Size & Duration: 
How many people are served or affected by this project and for how long?

Coordination & Duplication: 
Who else is addressing this need? Are there any coordination efforts between you and them?

Continuation: 
Does this project require continued funding? If so, identify the source of this future funding. Will this project save money in some way?

Evaluation: 
How will you determine that this project accomplished its goals? (The Foundation may request an update of the project in the future.)

If you are not able to purchase items or services in Merrick County, please list such items or services below and state why they are not able to be purchased in Merrick County.

 


All Applicants:
Enter your email address so we may contact you with any questions.
Email:

Signatures: (Your Organization):

Staff Officer ___________________________________________ Date ______________

Board Officer ____________________________________________ Date ______________

Once you have printed this application, please sign and date the original copy and make an additional 5 copies to submit with the other requested information mentioned at the top of this application. Please submit all your paperwork to:

Merrick Foundation, Inc.
P.O. Box 206, Central City, NE 68826

Questions or comments about this application may be forwarded to:
Phone: 308.946.3707 Fax: 308.946.3049
General Information: merrickf@hamilton.net