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COHOES SAVINGS FOUNDATION P.O. BOX 230 COHOES, NY 12047 Harry L. Robinson, Chairman Jacqueline E. Brennan, Exec. Dir.
APPLICATION
_________________________________________________________________________________ Legal Name of Organization
_________________________________________________________________________________ Address of Organization
______________________________ ___________________________ Date Founded Tax ID #
_________________________________________________________________________________ Chief Executive Officer (CEO)/ Executive Director
_________________________________________________________________________________ Contact person, if different from CEO/Executive Director
_____________________________ ___________________________ Telephone Number Fax Number
Principal purposes and services of your organization:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
List of Directors:
_______________________________ ____________________________
_______________________________ ____________________________
_______________________________ ____________________________
_______________________________ ____________________________
_______________________________ ____________________________
Page 1 of 2
Geographic Area Served:
Total Annual Budget: $_______________ Dates covered by this Budget: __________________________
Please describe the specific purpose or purposes for which funds are requested and will be used:
Identify other organizations working on this project, including a contact name and phone number for each.
State results you wish to achieve and how success will be measured.
Is your organization an IRS 501(C)3 Not-For-Profit? (yes or no) _____ (attach copy of IRS Notification)
I(We) hereby certify that if our grant request is approved, the funds will be used specifically as stated in this application.
I (We) further certify that at the completion of this project a report will be provided detailing the project’s accomplishments.
Signature of CEO/Executive Director
Print Name & Title Date
Page 2 of 2 Application 92501
COHOES SAVINGS FOUNDATION, INC.
SUPPLEMENTAL INFORMATION REQUIRED
In addition to providing the enclosed Application, would you please provide us with the following information, if applicable:
What is your turnover rate of employees.
Approximately how many people are going to be served with this project. How do you propose to keep the program going. List of foundation and corporate supports and all other sources of income, with amounts, for your current and most recent fiscal year. List of foundations, corporations and other sources that you are soliciting for funding and, to the best of your knowledge, the status of your proposal with each. One-paragraph resumes of key staff, including qualifications relevant to the specific request.
Attachments: Most recent Financial Statement Operating Expense Budget for current and most recent fiscal year. Your most recent annual report, if available. Recent articles about, or evaluations of, your organization, if available .. For More Information Contact: |
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