Grants Application Janvrin Land Acquisition

I. Application Information

Legal Name of Organization*

Division or Department Name (if applicable)

Are you a 501(c)3 Organization

Yes

No

Other Tax Exempt Entity?

If applicable.

EIN #

If your organization is not a 501(c) 3 tax exempt entity or division/department of a municipal/government agency or religious organization, please contact Thayer Talbott, 860.347.0025, for further information before completing the application.

Property /Place Name to be acquired*

Type of Funding Request - choose ONE

Land acquisition grant

Conservation Easement grant

Dollar Amount Requested $*

Total Project Cost $*

Summary Statement

Describe your proposed project or activity. This short summary of your request will be used in our database, materials, and publications. (maximum 500 characters with spaces)

III. Organization Information

Total Number of Directors/Trustees

Percent (%) of Directors/Trustees who contribute annually to Operations

Total number of Board meetings held last year:

Average number attending in person/virtually

Date most recent IRS Form 990 filed:

Year of Return

Organization's Fiscal Year

Organization's Total Operating Budget

Brief Background Statement

Brief background of the organization (Maximum 750 characts - including spaces, tabs, bullets, and other characters)

IV. Additional Information

Please Note: Documents requested must be uploaded in PDF format only. Other document formats will not be accepted by the form. Attempts to upload other file formats could result in a loss of all application data entered. Additional financial document, including the organization's most recent audit, annual report, and/or IRS Form 990 may also be required. Only provide this information if requested.

A. Estimated Revenue

Please include all the revenue sources supporting the acquisition, such as private donors (total estimate), Private Foundation, State funding, etc. Please designate which are pending and which are committed. To add an additional row, please click the " + " sign at the right side of the row in which you are working.

Itemized Funding Source

Amount ($)

Pending / Committed

Total Estimated Revenue

B. Estimated Expenses

Please include all estimated expenses for the acquisition, including property purchase, legal, staff, etc. To add additional rows, please click the " + " sign at the right side of the row in which you are working.

Itemized Expenses

Amount ($)

Total Estimated Expense

C. IRS Tax Exempt Determination Letter

Please upload a PDF copy of the organization's IRS Tax Exempt Determination Letter.

Accepted file types: pdf, Max. file size: 2 MB.

D. Organization's Current Operating Budget

Please include the organization's current operating budget as approved by the Board of Directors/Trustees.

Accepted file types: pdf, Max. file size: 2 MB.

E. Board of Directors and Officers

Please include professional affiliation and town of residence.

Accepted file types: pdf, Max. file size: 2 MB.

F. Supporting Material(s)

Please provide a topographical map showing the size and place of the property under consideration. This should include map designations of property boundary, surrounding roadways, and other pertinent information. You may also include other materials, such as brochures, that outline the goals and objectives of the proposed land acquisition project. Such documents may only be uploaded in PDF. Up to 5 documents are allowed.

Drop files here or

Accepted file types: pdf, Max. file size: 10 MB, Max. files: 5.

V. Organization Contact Information

Are you a new nonprofit applicant to the Community Foundation?

Executive Officer's Name*

Title*

Phone*

Email*

Contact Person

For this application, if different from above.

Contact Person Title

Contact Person Phone

Contact Person Email

Mailing Address

Street Address Address Line 2 City State ZIP Code

Street Address

If different than mailing address.

Street Address Address Line 2 City State ZIP Code

Website

Social Media Channels

Note: Social Media Platforms such as Facebook, Twitter, Instagram
Organization's page name is @__________ or other identifier

Social Media Platform

Organization's page name

VI. Requirements and Certifications

Marketing and Public Relations and Evaluation Requirements

Organizations receiving grants from the Community Foundation of Middlesex County must promote their funding awards according to the marketing and public relations guidelines established by the Community Foundation. The Community Foundation will host a seminar on marketing guidelines and tips for grantees annually. The Community Foundation’s Grantee Communications Kit may be downloaded on our website in the Nonprofit Resources section, middlesexcountycf.org/nonprofits/resources/forms-pr-guidelines/.
Furthermore, all CFMC grantees are required to submit a final evaluation regarding the use of CFMC funding and the outcomes, achievements, and results such funding supported. The evaluation requirements include qualitative and quantitative information, photos, stories, and examples of public acknowledgement of the award.
By signing the application below, the CEO/Executive Director/President understands the Community Foundation’s marketing and public relations requirements and evaluation requirements if awarded a grant.

Tax Exempt Standing and Use of Grant Funding Certification

By signing this application, the CEO/Executive Director/President is certifying that your organization is a qualified 501(c)3 organization or other charitable organization recognized and currently in good standing with the IRS, or 170(c)1 governmental agency. Should a grant be approved by the Community Foundation of Middlesex County, these funds may only be used for the purposes outlined in your original application; you must notify the Community Foundation if you are unable to do so. If grant funding is provided, you may only use these funds for charitable purposes as described in Section 170(c)2 of the IRS code, and funds may not be used for any political or lobbying activity. In addition, no tangible benefits, goods, or services may be received by our donors or by staff members of the Community Foundation of Middlesex County in exchange for grant funding.

Use of Grant Funds and Timing Certification

By signing this application, the CEO/Executive Director/President is certifying that you understand that funding awarded cannot be used for activities that occur before the award date which will be specified in a grant agreement letter, should funding be approved. You agree that if your organization receives a grant, it will not be used for expenses already incurred prior to the award agreement letter and will be spent within one year of the grant award agreement. If you are unable to use the funding during the year, you will contact the Community Foundation of Middlesex County.

Signature Certification

I certify that my printed name as stated and assigned below constitutes my signature and may be accepted as such.

Printed Name*

Title*

Date*

Thanksgiving Drive Oct 1 - Nov 9

I. Application Information

II. Funding Request Information

III. Organization Information

IV. Additional Information

V. Organization Contact Information

VI. Requirements and Certifications

Marketing and Public Relations and Evaluation Requirements

Tax Exempt Standing and Use of Grant Funding Certification

Use of Grant Funds and Timing Certification

Signature Certification

Thanksgiving Drive Oct 1 - Nov 9