Gift Of Animal Life Sanctuary, Inc. Application Form Applications must be postmarked by the application deadline date. Please check the appropriate application deadline. ___March 31st ____ September 30th 1. Organization or Individual Information a. Name _______________________________________________________________________ b. Mailing Address _____________________________________City _______________ c. State or Province ______________ Postal Code _____________ Country ________ d. Contact Person's Name ____________________________ Title ________________ e. Telephone Number _______________________ Fax Number __________________ f. E-Mail Address ___________________________ Web Site Address ______________ g. Please check a box indicating the type of applicant. ___IRS Designated Not-For-Profit Organization ___Individual ___Non-Designated Not-For Profit Organization ___Other _________ h. IRS or U.S. Tax Exempt or other Federal Identification Number ________________ We do not collect individual Social Security Numbers as part of the application process. If an individual applies for and receives support from GOALS, the individual will be required to provide their personal Social Security Number and be provided with appropriate forms indicating that they have received financial support from GOAlS. Funds will not be distributed to individuals until all necessary personal identification requirements are met. i. Please indicate the type of organization that best describes you. If you are an individual applying for assistance, please indicate the type of work this project supports. ___Animal Shelter ___Animal Adoption ___Animal Rescue ___Humane Society ___Animal Sanctuary ___Unwanted Pregnancy Prevention ___Educational ___Veterinary Services ___Unit of Government ___Other ________________________________________________________________ 2. Please state your mission. 3. Briefly describe the project that this grant may support. 4. How will this project address the stated GOALS objectives? 5. List the primary activities of the proposed project. a. b. c. d. e. 6. Using your own form, attach a narrative describing your project. This narrative should be no more than three pages in length and should include: History- a brief history of your organization or your work as an individual Need- how you determined the need that this project will address Who- who will be affected by this grant, the constituency you serve, the geographic area, and any minority groups Activities- a comprehensive list of the project's activities and expenses for each activity Budget- a detailed budget listing income and expense for the project this grant supports (cash, in-kind donation, etc.) Expense- how the grant money will be spent Timeline- a timeline or implementation schedule showing when the activities will occur And when they will conclude Impact- the estimated impact of the completion of your project using grant funds Evaluate- how you will evaluate and measure the impact of this project or activity. 7. Attach a copy of your organization's most recent financial statement and indicate whether or not it is an audited financial statement. If you are an individual, please provide your adjusted gross income (income less certain non-daily personal expenses) from your U.S. IRS From 1040 (the last number on the first page). If you not pay personal taxes in the United States, please provide your annual income as calculated in your country and state the country in which it is. Individuals should include an attachment listing donations they have received in the past two years in support of their work and the amounts of the donations and who the donations were received from (corporations, individuals, etc.). (U.S. Individuals - do not attach a copy of any of your personal tax forms). 8. If you are an organization, please attach a list of your current board of directors, their titles, terms and their experience associated with your organizations mission. 9. If you are an organization with not-for-profit status, please attach a copy of your U.S. IRS tax exempt certificate. 10. You may attach no more than seven total pages to this three-page application form (ten pages total). Within this limit of number of pages, you may also attach copies of letters of support or copies of photographs supporting your application. 11. Authorizing Official signature and Certification I certify that they information I am submitting on this application is true. I understand that any claims or application information determined to be false or misleading will result in the application being denied. I also affirm that I understand that The Gift Of Animal Life Sanctuary, Inc. (GOALS) may agree to fund or not fund this application based upon the stated and otherwise unstated objectives of GOALS and that I forfeit any rights to financial or other legal remedies associated with not receiving funding from GOALS. Furthermore, I agree that if I or my organization receives financial support or other support from GOALS, I (we) will provide the necessary reporting form by the deadline requested by GOALS and that will comply by all reasonable efforts to provide GOALS with photographs and other documents detailing the success of the project which the GOALS contribution supports, and I (we) agree to allow GOALS to use information about this project in GOALS publicity. Authorizing Officer Signature _______________________________________________________________________ Title _______________________________________________________________________ Printed Name of Authorizing Officer ________________________________________________________________________ Date ________________________________________________________________________ Please remember to: (You may choose to use this form to check off the boxes verifying that you have included the listed elements). Submit a completed application Attach a narrative Attach a financial statement - or personal income Attach a list of current board of directors Attach a copy of your IRS tax exempt certificate Sign and date your application