NAME OF NON-PROFIT:
TELEPHONE:
LOCATION:
CITY:
STATE:
DATE IRS DETERMINATION LETTER ISSUED:
MISSION OF NON-PROFIT:
PROJECT/PROGRAM FOR WHICH FUNDING IS NEEDED:
AMOUNT OF FUNDING REQUESTED:
STATEMENT OF FINANCIAL POSITION:
1. CURRENT ASSETS:
2. FIXED ASSETS:
3. CURRENT LIABILITIES:
4. LONG TERM LIABILITIES:
5. NET WORTH:
CONTACT PERSON:
EMAIL ADDRESS:
*Required information
