Charity Donation Grant Application Form

Luzerne County Bar Association Charitable Foundation, Inc.

Luzerne County Court House, Room 23

200 North River Street

Wilkes-Barre, PA 18711

Telephone # (570) 822-6712    Fax # (570) 822-8210

APPLICATION FOR A GRANT FOR 2015

(Needs to be Received by March 15th)

Date:

hereby applies to Luzerne County Bar Association Charitable Foundation, Inc. for a Grant and submits the following information in support thereof:

Full Name of Organization:

Full Name & Title of Applicant:

Address:

Telephone # and IRS Exemption Certificate #

*I certify, in completing this form, that our charitable organization is a registered 501(c) Non-profit corporation.

Amount of Grant Requested:

Purpose that the Grant will be used for:

(Use an additional sheet if necessary – Also attach any explanatory materials)

Please disclose whether your organization has ever received a Grant from our Foundation previously:

If the answer above is “Yes,” please disclose the year and amount received by your organization:

Does your organization have an Executive Director or other administrator/manager (whether full-time or part-time):

If the answer above is “Yes,” is this position a salaried position?:

Does your organization have any salaried staff (whether full-time or part-time or whether temporary, permanent, or seasonal):

If the answer above is “Yes,” please list the number of staff:

Please Provide the Names and Titles of the Officers Of Your Organization:

Please Provide the Names of the Members Of Your Organization’s Board of Directors:

Please provide any additional comments or information that you deem is relevant to your Grant application or would like to make known to the Luzerne County Bar Association Charitable Foundation, Inc.:

Return this form with any Attachments to the following:

Luzerne County Bar Assn. Charitable Foundation

c/o The Secretary

Luzerne County Court House, Room 23

200 North River Street

Wilkes-Barre, PA 18711

Or email to Joseph.Burke@luzernecounty.org