Minnesota Common Grant Application Form

Minnesota Common Grant Application Form
GRANT APPLICATION COVER SHEET
(You may reproduce this form on your computer)

Date of application: _________________ Application submitted to: _________________________

ORGANIZATION INFORMATION

Name of organization:
Legal name, if different:
Address:
City, State, Zip:
Employer Identification Number (EIN):
Phone:	Fax:	Web site:

Name of top paid staff:
Title:	Phone:	E-mail:
Contact person regarding this application:
Title:	Phone:	E-mail:

Is your organization an IRS 501(c)(3) not-for-profit? _____ Yes _____ No

IF NO, is your organization a public agency/unit of government? _____ Yes _____ No

IF NO, check with funder for details on using fiscal agents, and list name and address of fiscal agent:

___________________________________________________________________________

___________________________________________________________________________

Fiscal agent's EIN number: _________________________________

PROPOSAL INFORMATION

Please give a 2-3 sentence summary of request:
Population served:	Geographic area served:

Funds are being requested for (check one):
(Note: please make sure the funder provides the type of support you are requesting)

__ Capital

__ Other (list) _____________

Project dates (if applicable): _______________________ Fiscal year end: _______________

BUDGET

Dollar amount requested:	$
Total annual organization budget:	$
Total project budget (for support other than general operating):	$

AUTHORIZATION

Name and title of top paid staff or board chair: ___________________________________________

Signature __________________________________________________

Revised 12/2000

Cover Sheet | Narrative | Organization Budget | Project Budget

Back to Common Grant Index Page