Community Grant Application 2024 Please enable JavaScript in your browser to complete this form. - Step 1 of 3ORGANIZATION INFORMATION Political and Religious Organizations and Affiliations are excludedLegal Name of Organization *Date *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeName/Title of Person Submitting Application *FirstLastEmail *Office Phone Number *Direct Phone Number *Cell Phone Number *Is your organization an IRS 501(c)(3) not-for-profit *YesNoPlease give a brief description of your organization and the services it provides. * Please indicate below the counties within the Diverse Power service territory served by your organization and the estimated number of individuals served.CalhounHarrisRandolphChambersHeardStewartClayMeriwetherTerrellCowetaMuscogeeTroupEarlyQuitmanNextDoes your organization serve counties outside the Diverse Power service territory? If so, please indicate the additional counties served and the estimated number of individuals served by county. *Has your organization ever submitted a grant to Diverse Power Foundation? *YesNoDate of last grant request submitted *Has your organization ever received any funding from our Foundation? *YesNoDate(s) and amount(s) received *RequestProject/Program Name *Amount of Request *If partial funding is awarded, will you be able to complete this project / program? *YesNo List individually other funding sources for this project / program. Include amounts and whether received, committed, or pending:List individually other funding sources for this project / program. Include amounts and whether received, committed, or pending: Source #1Source #1Source #1 amountAmountSource #1 statusReceivedCommittedPendingStatusList individually other funding sources for this project / program. Include amounts and whether received, committed, or pending: Source #2Source #2Source #2 amountAmountSource #2 statusReceivedCommittedPendingStatusList individually other funding sources for this project / program. Include amounts and whether received, committed, or pending: Source #3Source #3Source #3 amountAmountSource #3 statusReceivedCommittedPendingStatusIf grant is awarded: Follow-up site visits to observe completed projects or ongoing programs may be conducted by Diverse Power Foundation staff and/or its Trustees. The applicant and the organization hereby authorize Diverse Power Foundation and Diverse Power to use their name(s), photographs, and any other information about the grant in various types of publicity. Required Information:Are you a member of the immediate family of any director of Diverse Power Foundation or of any director of Diverse Power?Person submitting application? *YesNoRepresentative of organization signing application? *YesNoBoard Officer of organization signing application? *YesNoMembers of the Board of Directors of the Foundation, members of the Board of Directors of Diverse Power or their immediate family are not eligible to receive any disbursement of funds from the Foundation.The information contained in this application is for the purpose of obtaining funding from the Diverse Power Foundation on behalf of the undersigned. Each undersigned understands that the information provided herein is used to consider the request for funding, and each undersigned represents and warrants that the information provided is true and complete and that the Diverse Power Foundation may consider this application as continuing to be true and correct until a written notice of a change is provided. The Diverse Power Foundation is authorized to make all inquiries they deem necessary to verify the accuracy of the application made herein.Submitting Representative's Signature *Corporate Officer's Signature *NextProject Descriptive in Detail *In a separate attachment, please describe your project in detail and explain how it will meet the criteria for the grant.Project Goals and Objectives *Specific – 1 page maximumCost estimates for equipment and contract work *Project implementation plan and projected time line *Most recent IRS Form 990 – page 1 *List of recurring annual funding sources (if applicable) *Organization's Name *Project Name *Note: All costs should be as close to actual as possible. Please include shipping and installation costs if applicable. The Foundation will not provide any additional funding in excess of the awarded grant. Item No. 1Description of Item to be Purchased *Quantity *Unit Cost *Total *Item No. 2Description of Item to be PurchasedQuantityUnit CostTotalItem No. 3Description of Item to be PurchasedQuantityUnit CostTotalItem No. 4Description of Item to be PurchasedQuantityUnit CostTotalItem No. 5Description of Item to be PurchasedQuantityUnit CostTotalItem No. 6Description of Item to be PurchasedQuantityUnit CostTotalItem No. 7Description of Item to be PurchasedQuantityUnit CostTotalItem No. 8Description of Item to be PurchasedQuantityUnit CostTotalItem No. 9Description of Item to be PurchasedQuantityUnit CostTotalItem No. 10Description of Item to be PurchasedQuantityUnit CostTotalItem No. 11Description of Item to be PurchasedQuantityUnit CostTotalItem No. 12Description of Item to be PurchasedQuantityUnit CostTotalProject TotalProject Total *Signature *Please type your name in the box above.Date *I'm not a robot * = Please solve the math problem above to proceed.PreviousSubmit Complete the online application or you may also download and print the physical application for submition.Mail to:Diverse Power FoundationAttention: School Grant OR P.O. Box 160LaGrange, Georgia 30241-0003
