Application – Emergency Relief Grant Organization Name: Year Founded:Name of the Contact Person: First Last Address: Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Website: Email: In which county is your organization headquartered? Organization FEIN/TaxID#: Is your organization affiliated with a national or other organization and do you use their EJN/TaxJD? Yes No If yes, please provide name of national/other organization: Is your organization a 50l(c)(3)agency? Yes No If yes, is it a Supporting Organization (this is a unique type of tax-exempt status for organizations that support another 50l(c)(3) entity-your IRS tax-exempt designation letter indicates if you are a supporting organization): Yes No If yes, what Type: I II III If no, what is the tax status of your organization (e.g. governmental entity, public school, other IRS classification, such as 501(c)(4))? NOTE: Only organizations with 50l(c)(3) status are eligible for operating support grants. Governmental agencies, schools, and organizations with other IRS classifications are not eligible for operating support.If your organization does not have 50l(c)(3) status and is not a governmental entity or public school, please list the name and address of your fiscal agent and attach the tax designation letter for this entity: File:Max. file size: 50 MB.Organization Background InformationWhat is your organization's mission?More Information:Provide background information on your organization, including when it was founded, current programs offered, geographic area, number of clients served and type of population served.Grant Request InformationIn the box below, provide a one-sentence description of the project for which you seek funding. State exactly what the funds will be used for and list how much you are requesting in grant funds.*You must request approval from JCCF, Inc. prior to submissions over $10,000.If this application is a re-submission of a previous application that was not funded, how has it changed since the prior submission? Have you discussed this re-submission with Foundation staff?Have you received funding from the Community Foundation of Jackson County's Community Grant Program previously? Yes No If yes, indicate when you received your most recent Community Grant and purpose of the grant. Project NarrativeReview Guidelines!Project Type: Capital & Equipment Projects Program Development Capacity Building Operating Support (requests to increase the organizations Financial Stability or Organizational Capacity) Please do not exceed ONE page.Narrative should include: Problem Statement, Goals & Objectives, Methods, Workplan, Timeline AuthorizationName and title of Director (top paid staff) or board chair: Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Last Signature:Use your mouse cursor or the touchpad to sign. Board of Education Approval on School Projects: Signature:Use your mouse cursor or the touchpad to sign. Application Checklist1. Application does not exceed 5-page limit and is paper-clipped (no staples). 2. Provide one copy of the application and the following attachments: o list of officers and board members o copy of IRS 501 (c (3) letter (not required for public schools or government agencies) o financial report (preferably audited) for most recently completed fiscal year, showing income and expenses o most recent 990 tax return or 990-N postcard o current organizational budget, showing income and expenses o actual estimates or invoices o budget attachment page(excel worksheet) 3. Submit application to the JCCF, Inc. Office,108 North Church Street, Ripley, WV25271 by the post mark deadline. For your convenience - a drop box is located in the lobby of the JCCF, Inc. Office -City National Bank building.PhoneThis field is for validation purposes and should be left unchanged.