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APPLICATION FOR TOWN OF MIDDLEBURG GRANT/CHARITABLE DONATION

2. APPLICANT INFORMATION:
   Only non-profit organizations and public institutions of higher learning in Middleburg are eligible for a Town of Middleburg grant

   Only non-profit organizations and public institutions of higher learning in Middleburg are eligible for a Town of Middleburg grant

4. Organization Name*

6. Contact Name*

7. Phone Number*

9. Email Address*

11. Mailing Address*

13. IRS Designation as Non-Profit Entity*

    Please attach a copy of your IRS designation as a non-profit entity

15. Date applicant attended a Town grant writing workshop or viewed the Town grant writing video*
    Date applicant attended a Town grant writing workshop or viewed the Town grant writing video

19. APPLICANT'S EXPERIENCE

21. Experience*

    Please identify the applicant's experience in organizing events

23. Partners*

    Please identify all partners assisting in the event, including their role.

25. Past Town grants*

    If the applicant has received past grants from the Town, identify the success of these grants. If no grants have been received, simply respond "N/A"

29. Acknowledgement of Town Grant Policy*

    1. Agreement to abide by terms of Town Grant Policy

    By checking this box, I agree I have read the Town Grant Policy and agree to abide by its terms and conditions. I understand that failure to follow the Policy can result in the denial of the grant application or the organization being required to return grant funds to the Town.

33. EVENT FOR WHICH FUNDING IS REQUESTED

35. Name of Event*

37. Date of Event*
    Date of Event Start Date

    Date of Event Start Time

    —

    Date of Event End Date

    Date of Event End Time

39. Type of Event*

    1. Special, Community or Cultural Event
    2. Program
    3. Capital Purchase
    4. Other (if other, describe below)

    1. Activity
    2. Special Circumstance (as defined in Town Grant Policy)
    3. Operations

41. Other:

    Describe

45. DESCRIPTION OF EVENT, PROGRAM OR ACTIVITY*

    Describe IN DETAIL the event and how it will be executed, including the timeline for the event from planning to completion. If more space is needed, provide additional information through an attachment at the bottom of the application.

49. GRANT FUNDING REQUEST

51. Amount of Funding Requested:*

53. Purpose/Goal for Grant Funding*

    Identify the purpose for which the funding is to be used, including the goal (i.e. if the purpose is marketing and the goal is to grow attendance, identify how the event will be marketed and the percentage of growth being targeted). If more space is needed to respond, please provide the additional information as an attachment at the bottom of the application.

55. If the funding request is for an item or service that will be purchased, attach a copy of the vendor's cost estimate and/or contract

    *Response to this item is mandatory if the funding request is for an item or service.

59. MEASURES OF SUCCESS

61. Identify how the organization will measure whether the goal was achieved*

63. Identify who within the organization will be responsible for measuring the outcome, including their knowledge and experience *

65. Date when measurements will be reported to the Town*
    Date when measurements will be reported to the Town

69. SUSTAINABILITY PLAN*

    Describe the organization's plan for becoming self-sustaining within three-years of obtaining the first grant award from the Town or the goal for obtaining other sources of funding (beginning in 2020 if previously received grants). PLEASE BE SPECIFIC. If additional space is necessary to respond, please provide as an additional attachment at bottom of application.

73. COMMUNICATIONS/MARKETING PLAN*

    Describe IN DETAIL how the organization plans to promote awareness of the event.

77. FINANCIAL RESOURCES/BUDGET

79. Organization's Cash on Hand*

81. Projected Revenues for Entire Event*

82. Projected Expenditures for Entire Event*

84. Budget*

    Attach a line item budget for the entire event, including all projected revenues and all projected expenditures. If net revenue projected, identify use of those funds.

86. AUDIT/990 IRS FILING*

    Attach a copy of your organization's most recent audit or IRS 990 filing

88. Other Sources of Public Funding*

    List any other sources of public funding being sought for the event, including the status of those applications.

90. Other Financial Support*

    List any businesses, organizations or individuals who are providing financial support, including the amount of their contribution. If more space is needed to respond, include information as an attachment at the bottom of the application

94. ADDITIONAL TOWN RESOURCES NEEDED FOR EVENT*

    Identify any additional Town resources needed for the event (i.e. Police, trash collection services, etc.) If none, simply reply "N/A".

98. OTHER ATTACHMENTS

    Upload any additional items the organization wishes the Town to consider as a part of the grant application

100. Additional Attachments

101. Additional Attachments

103. Additional Attachments

104. Additional Attachments

108. Electronic Signature Agreement*

     1. I agree

     By checking the "I agree" box above, you agree and acknowledge that 1) the information provided in this application is true and correct to the best of your knowledge, and 2) if received, the Town grant funds will only be used for the purposes for which they are awarded. By checking the "I agree" box above, you further agree 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

110. Electronic Signature

Leave This Blank:


112. 1. Receive an email copy of this form.
113. Email address

     This field is not part of the form submission.

114. Submit

* indicates a required field