1. Name of Organization Year Organized

Address Phone
 
 

Contact Person
 
 

Are you affiliated with any other organization?

If so, please name
 
 
 
 
 
 

2. Names and Officers of Governing Board (indicate if any are paid staff)
 
 
 
 
 
 
 
 
 
 

º
 
 
 
 
 
 
 
 
 
 

Number of paid staff: full time: part time:

Number of volunteer workers:

Number of volunteer hours per year:
 
 
 
 
 
 
 
 

3. Financial information ( from your last fiscal year)

Income:
from investments:

from Individuals/Business:

from Foundations and Corporations:

from Government:

Other:
 
 

Expenditures:

for Organization's Programs:

for Administration:

for Fund Raising:

Other:
 
 

Brief summary of Assets and Liabilities:
 
 
 
 
 
 

4. Summarize briefly your organization's objectives in general:
 
 
 
 
 
 
 
 
 
 
 
 

Along with six copies of this application, grant request (including: project description, timeline, and a detailed budget), send a copy of your most recent 501(c)(3) IRS ruling to Don Brackett, secretary, 630 Old County Road, Knox, Maine 04986

Deadlines: Applications must be postmarked by February 15 and August 15

USE 1ST CLASS, PRIORITY OR EXPRESS MAIL - WILL NOT ACCEPT CERTIFIED MAIL (or any service requiring pickup or signature, it is a 20 mile roundtrip to the Post office)

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