GreyStone Power Corporation

Application for Donation for Organization/Agency

All information requested must be completed for application to be reviewed. Applicants can only apply once a year.

*Name of Organization:
*Address:
*City:
*State:
*Zip Code:
*Phone Number:
*Email Address:
*Contact Person:
*Title:

May GreyStone Power and the GreyStone Power Foundation share your story? Please check the box if yes.
	Share your Story?:

Please indicate the amount requested. Maximum of $2,500 for a nonprofit requesting funds for the first time. The maximum amount any organization will be granted is $8,000.
*Amount Requested:
Is the organization requesting funding exempt from payment of income tax? If yes, indicate below and upload a copy of Form 501(c)(3) from the Internal Revenue Service using the upload tool below.
*Exempt from income tax?:
Upload Copy of Form 501 (c)(3):
A copy of the financial statement(s) for the most recent previous year should be uploaded below.
*Upload Copy of Financial Statement:

Please indicate the number of individuals, families or groups served in Bartow, Carroll, Cobb, Coweta, Douglas, Fayette, South Fulton and Paulding counties last year.
*Number Served Last Year:

*If you have been granted funds by the Foundation previously, please describe how those funds were used to assist individuals, families or groups served in Bartow, Carroll, Cobb, Coweta, Douglas, Fayette, South Fulton, and Paulding counties. If no funds were previously granted, enter N/A:

Does the agency serve outside of Bartow, Carroll, Cobb, Coweta, Douglas, Fayette, South Fulton and Paulding counties?

*Does Agency Serve Outside Counties?:
If the agency does serve outside counties, please indicate the number of individuals, families or groups served and the location (counties) where served.
Number Served:
Location:

*State the Purpose of the Request (include specifics of how funds will be used):

*List five other sources of funding for use of Request as described in the above question:

*How are the agency's programs measured for effectiveness? (Examples: number of people served, How funds are used, Success of programs):

Please list three references. For each, please list Name, Phone Number, Address (including City, State, and Zip Code).

*Reference 1 (Name, Phone Number, Address):

*Reference 2 (Name, Phone Number, Address):

*Reference 3 (Name, Phone Number, Address):

The information contained in this statement is for the purpose of obtaining funding from GreyStone Power Foundation, Inc. on behalf of the undersigned. The undersigned understands that the information provided therein is used in deciding to grant funding, and the undersigned represents and warrants that the information provided is true and complete and GreyStone Power Foundation, Inc. may consider this statement as continuing to be true and correct until a written notice of a change is provided. GreyStone Power Foundation, Inc. is authorized to make all inquiries they deem necessary to verify the accuracy of the statement made herein.

*Name of Representative:

Click here to draw your signature.

Signature of Representative

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*Date: