Make a Difference Grant Application

Name of Organization or School Requesting Grant:

Organization or School Website/URL

Contact Information

First

Last

Contact Email

Contact Phone

Organization or School Phone

Organization or School Address

Address Line 1

Address Line 2

City

State

Zip Code

Is your Organization or School a Non-Profit 501(c)(3)?

If you answered NO to the question above your organization or school is NOT eligible for the Make a Difference Grant (copy)

Type of Organization

Is your Organization or School located in Lakewood, Colorado?

If you answered NO to the question above your organization or school is NOT eligible for the Make a Difference Grant

If you are a Colorado non-profit corporation, is the organization in good standing with the Colorado Secretary of State?

If you answered NO to the question above your organization or school is NOT eligible for the Make a Difference Grant (copy)

Is the applicant a tax exempt 501(c)(3) organization?

If you answered NO to the question above your organization or school is NOT eligible for the Make a Difference Grant

Is your organization or school able to accepted ACH deposits (electronic deposits)?

If you answered NO to the question above your organization or school is NOT eligible for the Make a Difference Grant (copy)

Please upload a copy of the Organization or Schools IRS determination letter indicating 501(c)(3) tax exempt status.

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State the organization’s mission statement:

Purpose for grant or sponsorship

Specifically, how will the funds be used?

Describe the goals and overall impact of the project or program:

How will you measure success from use of the funds?

Upload Current W9

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