Defrees Grant Application

Defrees Family Memorial Fund Grant Application

* Required

Title

First Name *

Last Name *

Email Address *

Web Address

Name of Organization *

Date Founded *

Address *

City *

Phone *

Title within Organization *

Status *
501 (c) 3
509 (a)

If 509 (a) select status classification (found on IRS Determination Letter) *

Enter EIN/Tax ID *

Did you file form 990 last year? (If you answer YES please fax a copy of page 1 to 814-726-7099)
Yes
No

Have you previously requested DFMF funds? *
Yes
No

If you answered YES, enter date of request.

Amount of previous request.

Total Organization Revenue Current Year *

Total Organization Revenue Prior Year *

Enter primary sources of revenue *

Enter start date of Fiscal Year and attach last year's financial report *

Attach File for last year's Financial Report (100Mb Limit *)

Primary Sources of Income (grants, fees, etc.) *

Total Endowment *

Total Reserves *

Total Debt *

Total Cost of Project/Program *

Amount allocated from your Organization *

E-mail address

Phone Number *

Chairman of the Board of Directors *

List other funders for this specific project, indicate amount and whether they are Committed, Pending, or Not Yet. *

Number of Board Members *

Number of Staff *

Number of Volunteers *

Please provide a brief description of your organization, focusing primarily on the project for which you are seeking funding. Your summary should include the project’s objectives and goals, implementation methods, who the project will serve, a plan for *

Date of Application *

Amount requested *

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