Mark Clark Thompson Grant Application

Text/HTML

Mary Clark Thompson Grant test page

Organizational Information

Name of Organization

Address

Address 2

Phone

Fax

Website

Chief Executive (name and title)

Current Board President (name and title)

Primary Contact Phone

Primary Contact Email

Legal Name (as designated on 501c3 if different than above)

Year Organization was Incorporated

IRS 501(c)(3) Nonprofit?

Yes (Please upload IRS designation letter)

No (Please upload written agreement from auditor/fiscal agent)

NonProfit File (zip, pdf, jpg, png)

Upload

Federal ID #

NYS Charity Registration #

Total Organizational Budget for current fiscal year

Fiscal Year Start Date

Fiscal Year End Date

Organization's Mission

Have you previously applied for a Mary Clark Thompson Grant?

Yes

PA Year

PA Program Name

PA Amount Requested

PA Amount Awarded

Was your final report submitted to the Thompson Foundation?

Yes

Application

Program Name

Project Type

Capital/Equipment

Program

General Support of Operations

Time Frame Start

Time Frame End

Program Budget

Thompson Exclusive

Other Sources

Partial Funding Viable

Partial Funding Viable Detail

Geographic Area

Population Served

Problem Addressed

Program Description

Partnership Roles

Goals

Sustainability

Project / Program Budget

Instructions:

Fully complete the following budget form based on your proposed program/project. If your proposed program/project is receiving funding from other sources, please indicate the source and amount received. Add additional lines as necessary.

Line Items:

Budget Item Amount Budget Item Description

Budget Desc 1 $ Budget Note 1

Budget Desc 2 $ Budget Note 2

Budget Desc 3 $ Budget Note 3

Budget Desc 4 $ Budget Note 4

Budget Desc 5 $ Budget Note 5

Budget Desc 6 $ Budget Note 6

Budget Desc 7 $ Budget Note 7

Budget Desc 8 $ Budget Note 8

Budget Desc 9 $ Budget Note 9

Budget Desc 10 $ Budget Note 10

Additional Funding Source(s), if applicable:

Funding Desc 1 $

Funding Desc 2 $

Funding Desc 3 $

Funding Desc 4 $

Funding Desc 5 $

Funding Desc 6 $

Funding Desc 7 $

Funding Desc 8 $

Funding Desc 9 $

Funding Desc 10 $