*Choose Quarter 2023
Quarter 1-Jan-Mar 2023Quarter 2-Apr-Jun 2023Quarter 3-Jul-Sep 2023Quarter 4-Oct-Dec 2023

SECTION 1

1. Organization Name*

2. Mailing Address*

3. Phone Number*

4. Email Address*

5. Contact Person/Title*

6. Address to mail grant check if awarded, if different from Mailing Address

Check if this is a change from previous Grant Request.

7. Federal ID Number* (Required for all grant applications)

SECTION 2

1. State the mission of your organization.*

2. Describe the problem/situation this grant will help to address.*

3. Describe the impact of your organization on the Pickens County community.*

4. Did you receive PCCRA funding in a previous grant cycle?* (Check One) YesNo
--If Yes do you have funds remaining? (Check One) YesNo
--If Yes how much remains?
--When and how will the remaining funds be spent?
--If No, has a Grant Summary been submitted for spent funds? (See Section 5 below)
YesNo

SECTION 3

1. Amount of grant requested*:

2. Describe specifically how these grant funds would be spent.*

3. List existing and other potential funding sources for this activity.*

SECTION 4

1. Does your organization hold 501(c)(3) status?*YesNo
--If yes, please include 1st page of IRS response once a year.

--If no, why not?

2. Does your organization require formal commitment to any particular religious doctrine or faith in order to receive services?*
YesNo

3. Attach a copy of financial statement(s) and audit reports, if available, for the most recent previous year.*

Attach current year budget.* (Budget and financial information is to be included once a year).

4. Describe the administrative structure of the organization including staffing and governing body.*

5. Please provide a list of the organization’s officers and a copy of its By-Laws once a year.*

6. Check here if this is a request for a Capital Grant. Yes

SECTION 5

If funded, you are required to submit the PCCRA Grant Summary after funds are spent, or after one year, whichever comes first, describing how the grant funds were used. Send the PCCRA Grant Summary to the address noted above. Failure to submit this report may preclude your organization from future grant consideration.

The information contained in this grant request is for the purpose of obtaining funding from the Pickens County Community Resource Association, Inc. on behalf of the named organization. The undersigned understands that the information provided herein will be used to evaluate the application, and the undersigned represents and warrants that the information provided is true and correct. Authorization is granted to make all inquiries deemed necessary to verify the accuracy of the statements made herein.

Authorized Name*

Signature* (using mouse or finger)