LIVENGOOD TRUST APPLICATION FORM

Charitable Trust Application Form

Fields marked with an asterisk are required.

Organization Name

name of organization to be receiving grant

Tax ID or EIN number

no individual social security numbers

Address

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Phone

Website

Background Information

Briefly describe your organization

Mission Statement

Organization Contact Information

Name

Prefix

First

Last

Title in Organization

What is the contact's role in the requesting organization?

Contact Phone

Contact Email

Request Contact Information

*If different than organization primary contact

Name

Prefix

First

Last

Title

Individual's title in organization

Phone

Request Information

Project Title

Project Start Date

Project End Date

Project Description

Request Amount

List any previous grants from the Livengood Charitable Trust you have received in the last five years:

Have you applied to any other funding source?

Have you received funds from any other sources? Describe.

Please clarify your request by checking the appropriate boxes below:

Program Area:

Medical & Dental ExpenseAssistance Food & ProvisionsAssistance Hospice CareOther

Describe Other Program Area:

Is your organization supported by United Way?

YesNo

Are you a United Way Partner Agency?

YesNo

Attachments - Please upload your Project Budget, List of Board of Directors and Tax Status Letter.

All files must be a .pdf or Word Document format. The max file size is 50 MB.

File Upload

Up to 10 files, 50 MB each. Accepted: PDF, DOC, DOCX, XLS, XLSX, JPG, PNG.