MATCH4MILITARY

Please complete the form below and click 'Submit' when you are done.

Name of Organization

Executive Director

Address

City

State

Zip Code

Phone Number

The IRS Federal Employer Identification Number (EIN) is a 9 digit number (format: XX-XXXXXXX). Do not fill with Florida state tax exemption number. EIN

Has your organization qualified as a nonprofit, tax deductible entity, under the United States Internal Revenue Code 501(C)(3)? If "No", please enter application date and provide a copy of your organization's IRS for 1023 Nonprofit Status

Submitter Name

Submitter Title

REQUESTED GRANT AMOUNT

Total amount requested should not exceed $15,000 Total Amount Requested

Please provide a clear and concise statement of how these funds will be used. Do not defer your statement to other attachments included with this application. Use of Funds

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FINANCES

Organization's Fiscal Year End

Prior Year's Total Revenue

Percentage of Revenue used for Program Services

Percentage Explanation

Primary Source of Funding

ADDITIONAL INFORMATION

In addition to providing the information in this form, please include with your request the following attachments. Failure to include the listed attchments will result in your application being declined and having to restart this process.

Proof of the organization’s 501(c)(3) status
Most recent financial statement (audited statement preferred)
Most recent IRS form 990
Operating budget for the current fiscal year
Supporting documents regarding how funds will be used

To upload a file, Choose File, wait for file name to appear in line below, then select Upload File. The file name should then appear in the Uploaded Files list.

Upload Documentation

Uploaded Files:

I hereby certify that the aforementioned and enclosed information is complete and accurate and that the organization is in full compliance with all applicable laws, statues, ordinances, rules and regulations of any applicable governmental authority, including laws prohibiting support of terrorism.

Submitter Signature

Date

(*) indicates required field

Status:

Date of Decision: