Sharing Success Community Grant Application

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Contact Information

1. Contact's Name(Required)

First Last

2. Contact's relationship to nonprofit(Required)

Volunteer

Staff

Board Member

Board Officer

Other

If other, list nature of relationship to nonprofit.(Required)

3. Contact's Address(Required)

Street Address Address Line 2 City State ZIP Code

4. Contact's Phone Number(Required)

5. Contact's Email Address(Required)

Organization Information

6. Organization's EIN(Required)

7. Organization's Legal Name(Required)

8. Organization's Address(Required)

Street Address Address Line 2 City State ZIP Code

9. Organization's Phone Number(Required)

10. Organization's Mission(Required)

11. Organization's Website (if applicable)

12. Organization's Social Media Channels (if applicable)

13. Has this organization received funding from the PHP Sharing Success Community Grant program in the past?(Required)

Yes

14. If yes to question 13, what were your previous funding year(s), amount(s) and funding description(s)?(Required)

Previous Funding Year

Previous Funding Amount

Previous Funding Description

Proposed Program Information

15. Title of program to be funded(Required)

16. Main focus area for program: (Select all that apply)(Required)

Health & Well Being

Financial Support of Individuals

Education

17. Target population(Required)

18. REMC Counties Served (select all that apply)(Required)

The program must serve a target population living in at least one county served by REMC.

Randolph

Moore

Chatham

Montgomery

Alamance

19. Describe the desired results of your program. *(Required)

20. Describe the unmet need or your problem statement, and intended use of funds.(Required)

21. Organizational total budget (yearly or 2023)(Required)

22. Program total budget (yearly or 2023)(Required)

23. Would you accept partial funding?(Required)

Note: The maximum award is $2,000

Yes

24. If yes to question 23, what is the minimum amount you would accept?(Required)

Program Budget Breakdown

Program Budget Breakdown: Revenue Sources

Note: Please enter all sources of revenue or income and their amounts for your program. You can include up to $2,000 from this PHP Sharing Success grant. Examples are below. You do not have to use these categories in your program budget.

Example Revenue Sources

Board of Directors' donations: $5,000
Requested grant from PHP: $2,000
United Way funding: $15,000
Individual donations from members: $2,500
County government grant: $7,000
State government grant: $7,000

TOTAL: all amounts from above added up

The total amount for your budget should equal the total amount in question 22.(Required)

Program Budget Breakdown: Expenses

Note: Please enter all expenses related to your program. Examples are below. You do not have to use these categories in your program budget.

Total: all amounts from above added up

The total amount for your budget should equal the total amount in question 22.(Required)

Additional Information

27. Financial statement or most recent audit (if nonprofit total revenue is over $50,000). (Required)

Please select a choice below.

I will email to Nicole.Arnold@RandolphEMC.com

I will mail a copy to Nicole Arnold, REMC, PO Box 40, Asheboro, NC 27704.

Please follow up with me

28. IRS 990 form, IRS nonprofit approval letter, or postcard.(Required)

Please select a choice below.

I will email to Nicole.Arnold@RandolphEMC.com

I will mail a copy to Nicole Arnold, REMC, PO Box 40, Asheboro, NC 27704.

Please follow up with me

29. Supporting information about your organization or program

It is not required that you send supporting information. However, if you so choose, please select a choice below.

I will email to Nicole.Arnold@RandolphEMC.com

I will mail a copy to Nicole Arnold, REMC, PO Box 40, Asheboro, NC 27704.

30. Applicant Consent - Agreement to Terms:(Required)

The information contained in this statement is for the purpose of obtaining funding from PHP on behalf of the undersigned. The undersigned understands that the information provided herein is used in deciding grant funding, and the undersigned represents and warrants that the information provided is true and complete, and that PHP may consider this statement as continuing to be true and correct until a written notice of change is provided. PHP is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein.

I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.

31. Applicant Consent - Agreement to Statement:(Required)

32. Applicant Electronic Signature (Full Name)(Required)

33. Applicant Title(Required)

If the undersigned in question 32 is not the same as the contact at the beginning of the application, please indicate the undersigned's title.

Sharing Success Community Grant Application

Questions?

Contact Information

Organization Information

Proposed Program Information

Program Budget Breakdown

Program Budget Breakdown: Revenue Sources

Example Revenue Sources

Program Budget Breakdown: Expenses

Example Expense Categories

Additional Information

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