NAME OF ORGANIZATION, MAILING ADDRESS, E-MAIL ADDRESS (IF ANY), TELEPHONE AND FAX NUMBERS:

NAME OF PERSON TO CONTACT AND TELEPHONE NUMBER:

Please check the following that applies to your organization's Tax Status.

___ GOVERNMENT AGENCY

___ 501 (c) (3) PUBLIC ORGANIZATION*

___ APPLICATION SUBMITTED FOR TAX EXEPMT (IRC 501 (c) (3) Public Organizations) STATUS

___ RELYING ON FISCAL SPONSORSHIP BY ANOTHER MAINE ORGANIZATION (specify name:_______________________ ) which is itself a 501 (c) (3) organization**

*Attach a copy of the US Internal Revenue Service Letter which indicates your tax status.  If your organization is doing business as a D/B/A or has changed its name from the name on the IRS Exemption Letter please show proof of same.)
** Application must include fiscal sponsorship information specified in the Betterment Fund Statement of Grant Policies and Procedures.

TITLE OF YOUR PROPOSAL (NOT TO EXCEED 6 WORDS):

ATTACH:

• <>A SUCCINCT DESCRIPTION OF YOUR PROPOSED PROJECT, NOT TO EXCEED 3-5 PAGES, FONT SIZE 12 PT. OR LARGER
  
• <>A PROPOSED BUDGET FOR THE PROJECT, INCLUDING OTHER SOURCES OF SUPPORT
• <>LAST YEAR'S BUDGET FOR THE ORGANIZATION
• <>A LIST OF THE OFFICERS AND DIRECTORS (IF NOT SHOWN ON YOUR LETTERHEAD)
• <>COMPLETED COPY OF THE ATTACHED CODING SHEET