Form Center

2. APPLICANT INFORMATION:
   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. MISCELLANEOUS INFORMATION
21. Partners*

    Please identify all partners that are participating in the infrastructure project

23. Past Town grants*

    If the applicant has received past grants from the Town, identify these grants, including the date the grant was received.. If no grants have been received, simply respond "N/A"

27. 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. DESCRIPTION OF INFRASTRUCTURE PROJECT*

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

37. GRANT FUNDING REQUEST
39. Amount of Funding Requested:*
41. Purpose/Goal for Grant Funding*

    Identify the purpose for which the funding is to be used, (i.e. if the purpose is acquisition of building materials, identify the materials to be acquired. If more space is needed to respond, please provide the additional information as an attachment at the bottom of the application.

45. BENEFIT OF INFRASTRUCTURE PROJECT TO THE COMMUNITY
47. Identify how the community will benefit from the infrastructure project*
49. Identify who within the organization will be responsible for the infrastructure project, including their knowledge and experience in dealing with such projects.*
51. Date when the infrastructure project is anticipated to be completed. *
    Date when the infrastructure project is anticipated to be completed.
55. MAINTENANCE PLAN*

    Describe the organization's plan for maintaining the infrastructure and replacing it in the future as needed.  PLEASE BE SPECIFIC. If additional space is necessary to respond, please provide as an additional attachment at bottom of application.

59. COMMUNICATIONS/MARKETING PLAN*

    Describe IN DETAIL how the organization plans to promote awareness of the infrastructure and how it will benefit the community.

63. FINANCIAL RESOURCES/BUDGET
65. Organization's Cash on Hand*
67. Projected Capital Funding for the Infrastructure Project*
68. Projected Cost of the Infrastructure Project*
70. Projected Annual Maintenance Costs of Infrastructure Project*
72. Description of how the Organization plans to fund the annual maintenance costs.*

    Indicate NA if there are no anticipated annual, or other, maintenance costs

74. Budget*

    Attach a line item budget for the infrastructure project, including all projected funding and all projected expenditures. 

76. AUDIT/990 IRS FILING*
    Attach a copy of your organization's most recent audit or IRS 990 filing
78. Other Sources of Public Funding*

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

80. 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
84. ADDITIONAL TOWN RESOURCES NEEDED FOR PROJECT*

    Identify any additional Town resources needed for the project now and in the future. If none, simply reply "N/A".

88. OTHER ATTACHMENTS
    Upload any additional items the organization wishes the Town to consider as a part of the grant application
90. Additional Attachments
91. Additional Attachments
93. Additional Attachments
94. Additional Attachments
98. 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.
100. Electronic Signature
Leave This Blank:


102. 1. Receive an email copy of this form.
103. Email address

     This field is not part of the form submission.

104. Submit

* indicates a required field