Affiliate Grant Application

You are applying for a grant from the

Pipestone Area Community Foundation Endowment

Primary Contact Information

Person Completing Grant Application for the Organization

First Name:

Last Name:

Title:

Preferred Email:

Email:

Preferred Phone Number

Work Phone Number:

Home Phone Number:

Mobile Phone Number:

Grant Project Contact-Opportunity Contact Role

Organization represents a:

Due to IRS regulations, your application requires a "fiscal sponsor" partnership. Enter your organization's fiscal agent info in the section below.

Fiscal sponsor secured and entered below

Organization Information

Federal Tax ID Nonprofit Number (EIN):

This is the Federal Tax ID Number, also known as an EIN Employer Number. Nonprofits, Schools and Government Entities have them. (Not a State ID Number.)

Organization Name:

Contact Information for the top staff person at the above organization

First Name

Last Name

Title

What sector does organization serve?

Organization Phone

Street Address for the Organization

City

State/Province

Postal Code:

County

Website for Organization:

Generic Email Address for Organization:

What is the mission or purpose of your organization?

Area Organization Serves:

Use "Ctrl" to select multiple Counties.

Fiscal Sponsor Information

Due to IRS regulations, your application will require a "fiscal sponsor" partnership. A fiscal sponsor is a non-profit entity (i.e. a 501(c)3 public charity, a unit of government or a public agency) that accepts responsibility for the project/activities of an organization that does not have tax-exempt status, but whose project clearly demonstrates a public benefit.

Fiscal Sponsor Organization Name:

Fiscal Sponsor Organization represents a:

Fiscal Sponsor Federal TX ID Number (EIN):

This is the Federal Tax ID Number, also known as an EIN Number. (Not a State ID Number.)

Organization Website:

Generic Email Address for Organization:

Enter only email addresses such as "info@".

Contact First Name:

Contact Last Name:

Contact Title:

Work Email

Contact Work Phone:

Fiscal Sponsor Mailing Street Address:

City:

County:

State/Province:

Postal Code:

What is the mission or purpose of your organization?

Organizational Background:

Proposed Project Information

Project Title:

A 1-3 sentence summation of the project

Project Description and Expected Outcomes: (3-4 Sentences)

What our grant dollars would be used for:

Total Project Budget $:

Enter amount, no dollar sign.

Requested Amount: $

$500 or more.

List any other expected funding sources including amounts:

Will this project or event take place if funding is denied or if only partial funding is received?

Use the field below to provide additional details to your answer above and explain how the project might be impacted if full funding is denied or only partially granted.

Response is limited to 254 characters.

Project Start Date:

Select calendar date

Project End Date:

Select calendar date

Indicate the projected number to be served by your project:

Communities Enter an estimated number not a range.	People Enter an estimated number not a range.
Agencies Enter an estimated number not a range.	Businesses Enter an estimated number not a range.

Is there any additional information you would like to share to help us make a determination about your grant application?

Supporting Information:

Supporting documents for the organization or grant application can be uploaded here.

If our funding request is successful we agree to acknowledge the community foundation and use the foundation's logo in marketing or promotional materials for the project or event.Please check the box if you agree

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2. Complete your E-Signature
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Contact Information