COMMON GRANT APPLICATION

BARNITZ FUND JP MORGAN CHASE BANK

MIDDLETOWN COMMUNITY FOUNDATION

MIRIAM G KNOLL FOUNDATION

This application is not required but may be used to apply to receive funding from any of the above charitable organizations. Please see page two for delivery instructions for each organization.

Please use this page as a cover for your application, followed by information requested in the order specified. Proposals must be for programs serving residents of the Middletown area and meet the mission of the funding organization. Please keep a copy of the completed application for your records. Original applications will not be returned.

Name of Organization: ____________________________________________________
Important: Unless you are a governmental unit, a qualified church, or an entity covered by a group exemption, your name must be the same as on the IRS determination letter or you must submit documentation of your name change and notification to the IRS of that change.

Address: __________________________________________ Date established_________

Telephone: ___________________Fax: ____________________E-mail ______________

City, State, zip code: ____________________Employee Identification #______________

Chief Executive Officer: ____________________________Phone number: ___________

Chief Financial Officer: ____________________________ Phone number: ___________

Grant Contact Person: ______________________________Phone number: __________

The organization has in its possession a currently valid IRS letter stating that your organization has been determined to be:

_____an exempt IRC Section 501(c)(3) organization and has been classified as a public charity

described in IRC Section 509 (a) (1), (2) or (3)

_____ an exempt operating foundation described in IRC Section 4940 (d) (2)

_____ an entity covered by a group exemption. (Include copy of group exemption letter and

documentation of your inclusion)

Supplemental Information #2: Most recent Form 990. If the organization is not required to file form 990, please include most recent operating statement.

Supplemental Information #3: Your mission statement and roster of current trustees.

ABOUT THE PROJECT OR PROGRAM TO BE FUNDED

Title: _______________________________________________________________

Amount requested: $__________________________________________________

Implementation date: ____________________Completion date: ______________

Number of participants________________________________________________

In two or three sentences explain what the project or program is intended to accomplish, the benefits to the community and the activities that will lead to the desired outcome. If the request is for equipment, please explain how the purchase will benefit the community.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Supplemental Information #4: Enclose a narrative of no more than three pages answering the following:

(a) What is the community need to be met?

(b) How was this need determined?

(c) How does this program fit the mission of the organization?

(d) Who will be the primary beneficiaries if a grant is made?

(e) If this is a collaborative effort, please list partners and describe collaboration.

(f) Describe how the program will be evaluated for effectiveness.

(g) How will this program be funded?

a. If the grant is made, after grant money is expended.

b. If the grant is denied.

Supplemental Information #5: USE OF FUNDS

Total cost of project: __________________________

Grant requested from Foundation: __________________________

Other sources of funds and amounts:

____________________________ __________________________

____________________________ __________________________

____________________________ __________________________

____________________________ __________________________

Expenditure of grant money: Explain in detail how a grant from the Foundation will be used: give amounts for salaries and benefits, purchased services (consultants, outside service providers) supplies, equipment, and other uses.

Supplemental Information #6: Signed Grant Agreement.

Information for grant seekers:

Barnitz Fund of JP Morgan Chase: considers grants quarterly for organizations or programs serving the Middletown area. Applicants for grants of $2,500 or more should use this form. This form or a business letter may be used for grant requests of less than $2,500. Grant applications may be sent at any time to: Barnitz Fund; c/o Corporate Trust Officer; JPMorgan OH3-4131; 8044 Montgomery, Ste 152, Cincinnati, OH 45236. Requests will be considered at the next meeting of the distribution committee.

Middletown Community Foundation considers grant applications four times per calendar year. Each quarter is dedicated to a specific area of interest: (this application may be used)

March 1^st & September 1st - Recreation, The Arts, Festivals

- Community Development

June 1^st & December 1^st - Quality Education

- Human Needs

Please read the brochure “How to Apply for a Grant” for information on what the foundation does not fund.

Submit applications to: Middletown Community Foundation 36 Donham Plaza, Middletown Ohio 45042. Applicants will receive a confirmation of receipt. Applicants should expect at least a 60 to 90 day wait for notification of acceptance or denial of funding. The Foundation is not able to pay expenses incurred before formal written notification is made to an organization.

Miriam Knoll Foundation considers grants four times per year. Applicants for grants of more than $5,000 should use this form. Grant applications for amounts less than $5,000 may use this form or submit a business letter. Applications may be submitted at any time to: Executive Director, The Miriam Knoll Foundation, P.O. Box 220, Middletown, Ohio 45042. Requests will be considered at the next meeting of the trustees.

BARNITZ FUND OF JP MORGAN CHASE BANK

MIDDLETOWN COMMUNITY FOUNDATION

MIRIAM G. KNOLL FOUNDATION

GRANT AGREEMENT

The Governing body of ___________________________________ hereby submits a proposal for funding to _________________________________________, and agrees to the following conditions:

1. A policy of non-discrimination will be followed in all matters of employment, volunteer opportunities and the delivery of programs and services.

2. The grant, if made, will be used only for the purposes described in this grant proposal.

3. Requests for information/documentation from staff members of Grantmaker will be met in a timely manner.

4. Any change in tax exemption or inability to complete the project as proposed will be reported to the Funder’s staff in a timely manner.

5. If the request for funding is granted, we will acknowledge the funder’s support in all publicity relating to this project.

6. If the above conditions are not met, unexpended grant money will be returned to the Foundation immediately upon a written request received from the Funder.

The applying organization hereby accepts and agrees to the terms and conditions of this agreement.

____________________________________________ __________________

Signature, President of the Board of Trustees date

____________________________________________ __________________

Signature, Chief Executive Officer date

Norm/commongrantapp/rev9/16/03