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“Aid to Others”/Community Service Grant Funding Request Application Page 1 of 3 CITY OF DOUGLAS Local Government Funding Request Application Fiscal Year 2017 This application is to be used to request funds (a.k.a. “Aid to Others” funding) from the City of Douglas as authorized under W.S. §15-1-103(a)(xlv); §15-1-103(xxiii); §16-1-101 through 16-1-110; §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. The purpose of this application is to identify your organization’s need(s) for and the purpose of funding from the City of Douglas, and to simplify the process for City Council and staff, as well as for you as the requesting party. Please submit one original and six copies; please do not staple together. After submission, you will be required 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. 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 Karen Rimmer, 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 2017 IS (Month/Day/Year) 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. Primary Phone 5. Primary Email: 6. Website: 7. Complete Address: 8. Complete Mailing Address (if different from above): 9. Authorizing Person & Title: 10. Phone # (if different from above): 11. Email (If different from above): 12. Funding Amount Requested: $ 13. Have you attached a current Certificate of Liability Insurance Coverage for organization and/or for the Board of Directors, with $1 Million/$2 Million limits? YES NO If “No” to attachment and/or proper limits, please note that you will be required to provide this information prior to your application being finalized for presentation before the governing body. 5:00 PM, April 8, 2016 ---PAGE BREAK--- “Aid to Others”/Community Service Grant Funding Request Application Page 2 of 3 14. Please list your Board of Directors (first and last name and title for each member): 15. Purpose of Organization: Please be specific in explaining what you do and the benefit that you provide to the Douglas community: 16. Please list the proposed use of the requested funds and provide an explanation regarding why your organization is in financial need: ---PAGE BREAK--- “Aid to Others”/Community Service Grant Funding Request Application Page 3 of 3 17. Please list all other funding sources for your organization: 18. Have you attached your most recent financial statement for your organization showing total assets, liabilities, income, and expenses? YES NO 19. Have you attached a current budget for your organization? YES NO 20. Have you attached a proposed budget for next year? YES NO • A sample budget form has been attached to this application if you wish to utilize it. • Please note that you will be required to provide this information prior to your application being finalized for any presentation before the governing body. 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. SIGNATURE FOR APPLICANT DATE OF APPLICATION PRINTED NAME OF SIGNATOR TO BE COMPLETED BY CITY Date Received: All attachments received: YES NO If no, list all items needed: 1. 2. 3. 4. 5. SIGN