Organization’s Application

Pratt Northam Foundation
Organization’s Application for Grant
(Not for use by Individuals)

Pratt Northam Foundation
PO Box 104
Lowville, NY 13367

From:
(Name of Applicant)

(Street Address)

(City, State, ZipCode)

(Email)

PART I. Information about the Applicant

1. Is the applicant organized as a nonprofit organization under state laws governing charitable organizations?YesNo

If yes, what State or Commonwealth governs?

If no, please explain:

2. Has the applicant received a ruling or determination letter from the Internal Revenue Service about any of the following:

(a) Exempt statusYesNo
(b) Private foundation statusYesNo
(c) Grant-making proceduresYesNo
(d) Municipal body, Town, Village, County, etc.YesNo

Attach a photocopy of each such letter.
(a) copy of letter attached.

If any item is marked no, explain: (b) and (c). We are a civic association exempt under section 501(c) (4) of the Internal Revenue Code and thus are not subject to the
private foundation rules.

3. (a) Attach a copy of the applicant’s proposed project for the year in which the grant funds are to be used.

(b) If this grant will be a substantial and material part of the total budget, attach a copy of the latest information return (Form 990 or 990PF) filed by the applicant with the Internal Revenue Service.

(c) Describe the applicant’s purposes and activities in general.
Please respond to these questions on a separate sheet.

4. Is the applicant controlled by, related to, connected with, or sponsored by another
organization? YesNo
If yes, identify the organization including its purpose and activities, and explain the relationship:

5. List the name and address and title of each member of the applicant’s governing board. If municipal, list chief elected official and fiscal officer.
Officer 1
(Name)
(Title or Office)
(Street Address)
(City, State and ZIP Code)
Officer 2
(Name)
(Title or Office)
(Street Address)
(City, State and ZIP Code)
Officer 3
(Name)
(Title or Office)
(Street Address)
(City, State and ZIP Code)
6.Has the applicant (or any organization listed in 4) ever applied for or received A grant from this foundation? YesNo
If yes, give details:

PART II. Use of the Proposed Grant
7. Show the amount requested and explain in detail how it will be used. State whether the grant is to be earmarked For the use or benefit of any one person, group, or class of people. If so, for whom?

8. Person to contact who will be administering the proposed program.
(Name)
(Title)
(Street Address)
(City, State and ZIP Code)
(Area Code and Telephone Number)
(E-Mail Address)
From my own knowledge, I state that the information given in Parts I and II is correct.
The applicant organization has authorized me to make this application.
(Name)
(Date)
(Title or Office)
The information is Parts I and II is to help the grantor foundation meet the requirements of Section 4945 (h) of the Internal Revenue Code.
Part III. To be filled in by Pratt Northam Foundation
1. Evaluation by Grant or Program Committee:

10. Special supervisory or follow-up requirements, if any

11. Remarks :

(Date)
(Grant or Program Committee, Chrm.)

12. Action taken. (Person to approve action must initial and date)
a) Approved as requested
b) Approved as modified, see Remarks
c) Denied
d) Date of grant agreement
e) Amount of grant $
f) Date of grant
g) Date of interim report
h) Date of final report
i) Date File closed
10+48=?
Please leave this field empty.