Grant Form for Organizations

Walnut Cove Members Association

Charitable Grant Request

To be completed by the proposed organization

Organization Name and Name, address, phone number and email of the contact person of the organization to receive this grant:


Date of grant request: ___________         Is this organization a 501c(3)? ____________

What is the gifting dollar amount that is being requested for this organization? (This amount must not exceed $5,000.)   _________________________________________


What is the total overall budget for this project? ________________________________


What is the annual budget for the organization? _______________________________

Please attach a brief statement with the following information:

  1. The specific purpose of the grant
  2. How the grant will impact the community and number of individuals impacted
  3. The most recent Form 990 for your organization
  4. List of the Board of Directors for your organization

Please return this form and additional information requested no later than September 30, 2016 to:

Grants Committee Chair – Karen Spacek

1590 Country View Way Arden NC 28704

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