Charity Donation Application Form |

Organization Name:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name*

First Last

Email*

Website*

Phone*

How did you learn about G&G Charities?*

Organization's Mission Statement*

Federal Tax ID #*

Does the Organization Currently Have 501(c)(3) Status Under the Internal Revenue Service?*

Yes
No

Does the Organization Have a Written Nondiscrimination Policy and Practices Nondiscrimination in Employment of Staff, Recruitment of Volunteers and Delivery of Services?*

Yes
No

Program Area (check all that apply):*

Select All
Civic
Cultural
Education
Environmental
Health & Human Services
Youth Development

Geographic Area Served:*

How many years has the program existed?*

How many people are served by this program annually?*

Program Description- Approach & Strategy*

What Specific Needs or Problems In The Community Does This Program Address?*

Describe the individuals served by this program:*

Please include information such as age, gender, socioeconomic status and details about those benefiting from the program. Describe the specific objectives and outcomes of the program and how they will be measured.

If funded, will the G&G Charities grant enable your organization to serve additional clients? If so, how many?*

Program expansion is not required for funding. G&G Charities simply seeks to understand any incremental impact a grant may have on your program.

Please describe how your organization addresses a unique need and/or how they collaborate with similar organizations in the community.*

Total Annual Income*

Please Complete this section using your most recent audited financial statement.

Total Annual Expenses*

Please Complete this section using your most recent audited financial statement.

Total Program Amount:*

Please Complete this section using your most recent audited financial statement.

G&G Charities Request Amount:*

Financial Support*

Please list all other sources of financial support for this program. Indicate funding amount and wether each source is committed or pending (Sources of support may include grants from corporations or foundations, government contract, individual donor contributions or earned revenue from events or service fees.)

*

Yes

We acknowledge our organization may be funded in G&G publications, communications, and/or television spots.

*

Yes

We grant G&G Independent Insurance the ability to use our organization Name/Logo/Likeness for promotional purposes in print, television, radio, and other internal and external communications. No other consent or right to inspect or approve the promotional materials is required.

E-Signature*

Please Type Your First and Last Name

Charity Donation Application Form

Charity Application

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G & G Independent Insurance, Bentonville Location

Licensed in AR, OK, MO, KS, TX & TN