Fill and Sign the Commonwealth of Massachusetts Trial Court Cd Copy Order Form

The Samuel L. Phillips Family Foundation Grant Application Form For additional information please visit wellsfargo.com/privatefoundationgrants/phillips. General information Federal Tax ID Number: ______________ Date of tax-exempt status: ______________ Organization name: ____________________________________________________ Address: ___________________________________________________________ City: ____________________________ State: _______ Phone: __________________________ Zip code: _____________ Fax: _____________________________ Primary contact for this application: Salutation: _____ First: ______________ MI: _____ Last: ____________________ Title: ______________________________________________________________ Phone: __________________________ Email: ____________________________ Brief description of your organization’s mission and primary activities: (Up to 2 pages of additional detail may be attached.) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Request summary Title of project:_______________________________________________________ Grant amount requested: $_______________ Total project cost: $________________ Summary of project, the issue and its importance, the objective, a timetable, and your plan: (Up to 2 pages of additional detail may be attached to this application.) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Updated 2/28/2011 Page 1 of 3 Primary funding for this project: Committed Amount ________________________________________________ _______________ ________________________________________________ _______________ ________________________________________________ _______________ ________________________________________________ _______________ ________________________________________________ _______________ Pending (include expected determination date) Amount ________________________________________________ _______________ ________________________________________________ _______________ ________________________________________________ _______________ ________________________________________________ _______________ ________________________________________________ _______________ Project budget and future funding plans if this project is to continue: (Describe below and attach a spreadsheet that breaks down the total project costs by category.) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ If your organization were to receive only partial funding of your grant request amount, would the project continue? If yes, identify the priority components of the project budget. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Describe collaborative efforts—formal or informal—you have established with organizations working on similar issues or providing similar services. How do you coordinate with or complement one another? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Updated 2/28/2011 Page 2 of 3 Financial resources Organization’s net assets: $_________________ as of last fiscal year end (mm/yy) ______ Revenues and expenditures for last fiscal year Income: ____________________________ Expenditures: ____________________ Current fiscal year budget Income: ____________________________ Expenditures: ____________________ Sources of funding: _______% Membership _______ % Annual campaign, events, etc. _______% Fees _______% Government _______% United Way/United Arts Council _______% Other Human resources Full-time paid staff: _______ Part-time paid staff: _______ Volunteers: _______ Consent to terms I have carefully reviewed the guidelines and requirements of this application and agree to comply with all stipulated conditions should a grant be awarded. ________________________________ Signature ________________________________ Date ________________________________ Print Name ________________________________ Title Updated 2/28/2011 Page 3 of 3