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“Aid to Others”/Community Service Grant Funding Request Application Page 1 of 4 CITY OF DOUGLAS Community Service Grant “Aid to Others” Application Fiscal Year 2027 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 [PHONE REDACTED], and ask for Devon Litzsinger, City Clerk. 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 2027 IS FRIDAY, APRIL 3, 2026. 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 NO 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 NO ---PAGE BREAK--- “Aid to Others”/Community Service Grant Funding Request Application Page 2 of 4 15. Number of constituents served? 16. Did you submit prior year required quarterly reports and Key Progress Indicator updates? Quarter 1 Quarter 2 Quarter 3 Quarter 4 17. Please list your Board of Directors (First/Last Name & Title/Office): 18. Please provide the name of your Board of Directors and/or Director and/or Member of the Staff Executive Team with financial oversight attend and complete the State of Wyoming financial Training? Please attach the certification. 19. Purpose of Organization: Please be specific in explaining what you do and the benefit that you provide to the Douglas community: 20. What are your most recent benefits provided to the community? 21. Please list all other funding sources and budgeted amounts for your organization. ---PAGE BREAK--- “Aid to Others”/Community Service Grant Funding Request Application Page 3 of 4 THIS SECTION MUST BE COMPLETED IN FULL FOR FUNDING CONSIDERATION City Priorities Alignment: Which City of Douglas priority area(s) does your project advance? (Select all that apply. For each selected area, provide a brief justification describing the project benefit and how success will be measured.) ☐WTR: Water Rights Supply & Distribution: Increase water rights and storage; reduce consumptive use; improve water distribution; educate a water-wise city. ☐INFR: Built & Natural Infrastructure Extension of Life: Extend the useful life of City infrastructure; landfill sustainability; tree canopy management. ☐ECON: Economic Diversification: Economic growth and business development; develop an attractive community and vibrant downtown; housing; OneDouglas unified community vision; district development. ☐ORG: High Performing, Safe & Trained Organization: Develop and sustain a High Performing Organization (HPO), including safety and training. ☐QLI: Quality of Life Improvements: Safe mobility for all; outdoor recreation; host cultural events and build partnerships to promote the arts; showcase Douglas’s heritage to inspire pride in our past; Douglas Community Center. ☐ASC: Appealing & Safe Community: Enhance safety of residents; enhance police operations; multi-lingual communications. 22. How does your project align with the City’s Strategy(ies) selected above? (Example: “Our initiative supports the ‘Appealing & Safe Community’ priority by launching a bilingual communication campaign, ensuring accessibility for all residents.”) 23. How will you measure success? Provide Key Performance Indicators (KPI), such as the number of individuals served, economic impact, safety improvements, or community engagement growth. (Example: “We will track the number of participants, community feedback, and economic impact reports to measure success.”) ---PAGE BREAK--- “Aid to Others”/Community Service Grant Funding Request Application Page 4 of 4 24. How will this funding help you achieve the identified goals? Provide specific details on how city funding will be used to advance these priorities. (Example: "Funding will allow us to expand our after-school program, serving an additional 50 students and increasing literacy rates by 15%." 25. Attach your most recent financial statement for your organization showing total assets, liabilities, income, and expenses. 26. Attach a current budget for your organization. 27. Attach a proposed budget for next year. 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: Valid Application Complete? YES NO NOTE: AWARDS WILL NOT BE MADE WITHOUT COMPLETE INFORMATION SIGN