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Application

Grant Application

Name(Required)
Organization Address(Required)
MM slash DD slash YYYY
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      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.
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