Organization's Legal Name and D/B/A, if applicable

Address

Website

Contact Person

Title

Email

Phone

501(c)(3)Tax ID #

Year Founded

Organization's Annual Budget

Percentage of Salaries & Compensation / Annual Budget

Organization's Mission Statement: Briefly describe mission and core purpose; please highlight any key programs, if applicable

Name of Program / Activity / Use / Scholarship

Amount Required

Total Project / Activity Cost / Sponsorship; if applicable.

Need: What are the community needs which this grant will try to address? Include geographical location of people services and number of people who will benefit?

Purpose: Please describe the nature and purpose of this program and/or sponsorship.

Use of Funds/Other Funding Sources: Please detail the use of funds. If there are other contributors to this project, please include organization's name, amount of funds and status.

Media Promotion of Max Cares Foundation, Inc.: Please detail the ways you will promote Max Cares Foundation's support of your organization to the public

Other: If only partially funded by MCF, would the project still occur?
YesNo
Please Explain.

Attachments

a. Detailed Budget

include a detailed budget for the project. Please use the attached form or you may reproduce the form on your computer provided the format is closely followed.

b. Financial Statements

include your organization's most recent year-end income/expense report and balance sheet and a current operating budget.

c. IRS Determination Letter

include a current IRS determination letter showing exemption from federal income taxes under Section 509(a) of the IRS Code and your 501(c)(3) status.

d. Most recent Form 990 of your organization

Applications may also be submitted via:

Email:
Grants@maxcaresfoundation.org

U.S. Mail:

Max Cares Foundation, Inc.
249 Pearl St., 3rd Floor, Hartford, CT 06103

Applicant Signature

Title

Application Date