Grant Application

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Organization Information

Organization Name(Required)

Organization Contact Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Contact Phone(Required)

Contact Email(Required)

Organization Mission Statement(Required)

Tax Exempt Status(Required)

This organization is registered as a 501(c)(3) organization.

Federal Tax ID(Required)

Project Information

Project Name(Required)

Project Chairperson Name(Required)

First Last

Chairperson Phone(Required)

Chairperson Email(Required)

Total Cost of Program(Required)

Amount Requested(Required)

Estimated Time Period/Duration of Project(Required)

Project Descriptions

Provide a description of the scope of the project(Required)

Include goals/objectives, who will work on the project and timeline.

How does this project impact Pickaway County and how will it be advertised or promoted?(Required)

Evidence of need for the project(Required)

Provide information on the problem you intend to address with this program and why. Include in bulleted format specific data and local statistics that support your case. Include sources.

Describe the resources your organization will dedicate to this program(Required)

Include other funding streams

What are the expected results from this program?(Required)

Describe “how many?” Examples may include number of classes taught, sessions conducted, materials distributed, participants served, service hours provided, etc.

What constitutes success of the program?(Required)

Include key performance indicators and specific numbers.

Additional Documents

Summary of the Proposed Project(Required)

One page, double spaced

Accepted file types: doc, docx, pdf, jpg, jpeg, Max. file size: 200 MB.

Proposed Project Budget(Required)

Showing all sources of income and expenses, including other grants received.

Accepted file types: doc, docx, pdf, csv, xls, xlsx, Max. file size: 200 MB.

Organization’s Budget(Required)

Showing all sources of income and expenses, including other grants received.

Accepted file types: doc, docx, pdf, csv, xls, xlsx, Max. file size: 200 MB.

List of all Board Members(Required)

Accepted file types: doc, docx, pdf, jpg, jpeg, csv, xls, xlsx, Max. file size: 200 MB.

Copy of Organization’s Most Recent 990(Required)

Accepted file types: doc, docx, pdf, jpg, jpeg, Max. file size: 200 MB.

IRS Designation Letter(Required)

Accepted file types: doc, docx, pdf, jpg, jpeg, Max. file size: 200 MB.

Consent

Organization Contact Signature(Required)

I certify that the information provided in this application is true to best of my knowledge.

PCCF Giving

$140,480.42 total grants issued by PCCF Board in unrestricted funds between 2001 and 2017.

$3.4 million in scholarships and grants has been issued from all funds held by PCCF.