Grant||Application Grant Application Organization Name(Required) Name(Required) First Last Phone(Required)Email(Required) Organization Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Incorporation Date(Required) MM slash DD slash YYYY Are you tax exempt?(Required)YesNoTax Exemption Number If awarded, how many estimated people will benefit?(Required)Dollar amount you are requesting(Required)Percentage of award will go to salary/employee costs(Required) If your grant request amount is not met, or met in part by JSL, will your program still be operational? If not, please explain why in detail.(Required)Please explain what project(s) and a description of, this award will go to benefit(Required)Total Cost of this Project(Required)What are (or will be) your other sources of funds for this project?(Required)Please explain in detail, how your project will benefit the citizens of Mesa County(Required)If needed, upload a further project document Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 128 MB, Max. files: 5. What percentage of award will benefit Mesa County?(Required) Is this an ongoing project?(Required)YesNoProgram Specific Budget - Current Year Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 128 MB, Max. files: 5. How many paid employees does your organization have?(Required)How many volunteers are working on this project?(Required)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?(Required)YesNoI certify that the aforementioned agency has received tax exempt status under the internal revenue code 501(c)(3). Yes I certify that the aforementioned agency's organizing document and by-laws are up to date and applicable to the agency's current operation. Yes I certify that the aforementioned agency has been incorporated as a non-profit organization for at least two years before completing this application. Yes 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. Yes 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. Yes 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. Yes I certify that the aforementioned agency has an independent annual audit or review prepared by a CPA. Yes I certify that the aforementioned agency has filed a current form 990 with the Internal Revenue Service. Yes I am the duly appointed representative of the aforementioned organization, authorized to certify and affirm statements of this eligibility determination form. Yes Upload any other documentation you wish to have considered. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 128 MB, Max. files: 5. By signing this application, you agree that all information submitted on this application is true and correct to the best of your knowledge.(Required) CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
