GRANT APPLICATION

WHICH GRANT ARE YOU APPLYING FOR? *

IF AWARDED FUNDING FROM JSL, WOULD YOUR ORGANIZATION BE WILLING TO ADD JSL'S LOGO TO YOUR PROMOTIONAL MATERIAL AND/OR DISPLAY SIGNAGE IN A COMMON AREA OF YOUR AGENCY? *

I CERTIFY THAT THE AFOREMENTIONED AGENCY HAS RECEIVED TAX EXEMPT STATUS UNDER THE INTERNAL REVENUE CODE 501 (C)(3). *

I CERTIFY THAT THE AFOREMENTIONED AGENCY'S ORGANIZING DOCUMENT AND BY-LAWS ARE UP TO DATE AND APPLICABLE TO THE AGENCY'S CURRENT OPERATION. *

I CERTIFY THAT THE AFOREMENTIONED AGENCY HAS BEEN INCORPORATED AS A NON-PROFIT ORGANIZATION FOR AT LEAST TWO YEARS BEFORE COMPLETING THIS APPLICATION. *

I CERTIFY THAT THE AFOREMENTIONED AGENCY HAS AT LEAST A THREE-MEMBER LOCAL BOARD OF DIRECTORS OR ADVISORY BOARD/COUNCIL WHICH GOVERNS THE AFFAIRS OF THE ORGANIZATION. THE BOARD/COUNCIL INCLUDES VOLUNTEERS WHO REPRESENT A CROSS-SECTION OF MESA COUNTY RESIDENTS. *

I CERTIFY THAT THE AFOREMENTIONED AGENCY EXISTS TO SERVE PEOPLE GENERALLY, AND HAS ADOPTED A POLICY OF NON-DISCRIMINATION THAT IS IN COMPLIANCE WITH ALL STATE AND FEDERAL LAWS, APPLICABLE TO PERSONS SERVED, STAFF EMPLOYMENT AND MEMBERSHIP ON ITS GOVERNING BOARD. *

I CERTIFY THAT THE AFOREMENTIONED AGENCY HAS AT LEAST ONE STAFF PERSON, SALARIED OR UNSALARIED, ASSIGNED AT LEAST HALF TIME TO CONDUCT AND/OR ADMINISTER THE ACTIVITIES OF THE ORGANIZATION. *

I CERTIFY THAT THE AFOREMENTIONED AGENCY HAS AN INDEPENDENT ANNUAL AUDIT OR REVIEW PREPARED BY A CPA. *

I CERTIFY THAT THE AFOREMENTIONED AGENCY HAS FILED A CURRENT FORM 990 WITH THE INTERNAL REVENUE SERVICE. *

I AM THE DULY APPOINTED REPRESENTATIVE OF THE AFOREMENTIONED ORGANIZATION, AUTHORIZED TO CERTIFY AND AFFIRM STATEMENTS OF THIS ELIGIBILITY DETERMINATION FORM. *