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Application
Application Contents

Page 1.
- DATE
- GRANT REQUEST FROM
- OFFICERS, DIRECTORS OR TRUSTEES OF ORGANIZATION
- NAME, ADDRESS, PHONE NUMBER OF CONTACT PERSON
- AMOUNT REQUESTED
- DESCRIPTION OF PROJECT WITH IMPACT STATEMENT/OBJECTIVES AND NEEDS

Page 2.
- OTHER FUNDING SOURCES FOR THIS PROJECT
- ITEMIZED BREAKDOWN OF EXPENSES FOR THIS PROJECT
- TIMETABLE FOR PROJECT AND PLANS FOR SUSTAINING THE PROJECT AFTER THE GRANT
- IRS TAX EXEMPT STATUS (Please include copy)
- THOSE WHO WILL BE MANAGING THE PROJECT

Page 3.
- HOW DO YOU PLAN TO EVALUATE THIS PROJECT
- DESCRIPTION OF PUBLIC RELATIONS PLANS/FOUNDATION FUNDING
- OTHER PERTINENT INFORMATION
- TO BE SIGNED BY ORGANIZATION’S PRESIDENT AND/OR INDIVIDUAL TO WHOM FUTURE QUESTIONS AND CORRESPONDENCE MAY BE ADDRESSED
- SIGNATURE

Page 4.
- GRANT APPLICATION CERTIFICATION
Grant Applicant hereby certifies that it does not discriminate on the basis of race, national origin, religion, gender, gender preference, age or disability (“non-discrimination factors”) in its policies, practices, services, or standards for participation in its programs, except to the extent any such program lawfully provides services to a limited segment of the population based on any such non-discrimination factor. It is expressly understood and agreed that the Western Indiana Community Foundation is not a joint participant in, nor provider of, any of the Grant Applicant’s programs or services. The Western Indiana Community Foundation’s role in Grant Applicant’s programs and services is limited solely to making grants and assuring that grants are administered in accordance with the terms of the approved application. The Grant Applicant represents and warrants that it will use all granted funds in accordance with applicable laws. Grant Applicant agrees to indemnify, and hold the Western Indiana Community Foundation harmless from any liability imposed on the Western Indiana Community Foundation based on any conduct or omission occurring in connection with a program or service of Grant Applicant for which the Western Indiana Community Foundation has provided a grant.
- DATE
- SIGNATURE
- PRINTED NAME
- TITLE



Western Indiana Community Foundation
135 S. Stringtown Rd.
P.O. Box 175
Covington, IN. 47932

Phone: 765-793-0702
Fax: 765-793-0703
Email: info@wicf-inc.org

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