COMMUNITY GIVING FUND

Application

The Delaware River Port Authority (DRPA) requests that your organization complete the information below to assist in the evaluation of your request. Incomplete applications will not be reviewed. Please send your most recent audited financial statement and a copy of your 501(c)(3) certification. You may also include any other documentation you feel would be of assistance in the review process to supplement the questions on this application. You may include event invitations. Send to DRPA, Attn: Maria Mondile, Manager, Customer and Community Relations, P.O. Box 1949, Camden, NJ 08101-1949.

Legal name of organization as it appears on 501 (c)(3) IRS form (please send a copy of the 501(c)(3) certification):

Mailing Address:

City:		State:		Zip:

Chair or President of Organization:

Requestor’s Name and Title:

Contact Person’s Name and Title:

Phone:

Fax:

Email Address:

1. Amount Requested:

Date:

2. Describe how the funds you are requesting would be used (if this is for a specific event, describe the underlying purpose of the event):

3. Statement of Objectives:

4. Intended Beneficiaries:

5. Desired outcome and methods for evaluating results:

6. Timetable for requested funds:

7. Detailed program or program budget (please send separate budget schedule or program listing if necessary):

8. Describe any related events or programs:

9. Sources of other anticipated or committed funds:

10. Please provide a list of your Board of Directors and their affiliations.

11. Please send your organization’s most recent audited financial statement.

12. If your organization has received DRPA funding in the past, describe the status of program or projects previously funded and level of funding:

13. Please list any publicized acknowledgment or other benefits to the DRPA if your request is selected.

14. In accepting a contribution from the DRPA, the recipient agrees to assist the Authority in evaluating the contribution through periodic visits and requested reporting.

Agree Disagree