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“Aid to Others”/Community Service Grant Funding Request Application Page 1 of 3 CITY OF DOUGLAS Community Service Grant “Aid to Others” Application Fiscal Year 2022 This application is to be used to request funds (“Aid to Others” funding) from the City of Douglas as authorized under W.S. §15-1-103(a)(xlv); §15-1-103(xxiii); §35-1-613(a)(iv); and §35-1-614(b). The completion of this application does not guarantee approval of funding, nor does it guarantee that approved funds will be equal to the amount requested. Please submit one original and six copies; please do not staple together. After submission, you will be requested to appear at a joint Study Session before the Douglas City Council and the Converse County Commissioners in order to present your application and answer any additional questions that may arise. PLEASE NOTE that this application is a request for funding from the City ONLY and any funding request to the County must be made to the County Clerk as a separate application and process. City Council will make a final determination at the time the municipal budget is approved for the following fiscal year. If you have additional questions regarding this application or this process, please contact City Hall at 307-358- 3462, and ask for Chaz Schumacher, City Clerk, or Mary Nicol, City Treasurer/Administrative Services Director. Please complete ALL questions. If a question does not apply to your organization, please indicate as such. If you need additional space, please attach extra pages to this application and reference extra pages within that answer blank. APPLICATION SUBMISSION DEADLINE FOR FISCAL YEAR 2022 IS FRIDAY, APRIL 9, 2021. GRANTEE (Applicant) INFORMATION: 1. Organization/Company Name: 2. Company TIN/SSN: 3. Type of Non-Profit Organization [e.g. 501(c)(3) or not for profit, governmental, etc.]: 4. Status Letter and W-9 Attached: YES q NO q If no, please explain: 5. Primary Phone 6. Primary Email: 7. Website: 8. Complete Address: 9. Complete Mailing Address (if different from above): 10. Authorizing Person & Title: 11. Phone # (if different from above): 12. Email (If different from above): 13. Funding Amount Requested: $ 14. Current certificate of liability insurance coverage for organization and/or for the Board of Directors, with $1 Million/$2 Million limits: YES q NO q ---PAGE BREAK--- “Aid to Others”/Community Service Grant Funding Request Application Page 2 of 3 15. Please list your Board of Directors (First/Last Name & Title/Office): 16. Purpose of Organization: Please be specific in explaining what you do and the benefit that you provide to the Douglas community: 17. Please list the proposed use of the requested funds and provide an explanation regarding why your organization is in financial need: 18. Please list all other funding sources for your organization, including grants and any funding received from the CARES Act funding: ---PAGE BREAK--- “Aid to Others”/Community Service Grant Funding Request Application Page 3 of 3 19. Have you attached your most recent financial statement for your organization showing total assets, liabilities, income, and expenses? YES q NO q 20. Have you attached a current budget for your organization? YES q NO q 21. Have you attached a proposed budget for next year? YES q NO q I hereby certify the above information to be true and correct to the best of my knowledge. I understand that you may deny or revoke my application if the information is false. AUTHORIZED SIGNATURE DATE OF APPLICATION PRINTED NAME TO BE COMPLETED BY CITY Date Received: Reviewed By: Application Complete? YES q NO q