APPLICANT:
PROJECT TITLE:
AMOUNT REQUESTED:
DATE:
SUBMITTED BY:

NAME:
TITLE:
TEL. NO.:
ADDRESS:

  1. Full name of organization.
    1. Statement of what organization is chartered to do, with reference to authorizing agency and date of authorization. INCLUDE PHOTOCOPY OF ARTICLES OF ORGANIZATION.*
    2. Photocopy of TAX EXEMPTION STATUS LETTER, and a complete copy of the Internal Revenue Service DETERMINATION LETTER regarding your private foundation status.* The Foundation does not grant financial assistance to other private foundations.
    3. Copy of its most recent Form 990 as filed with the IRS, or, if none, a copy of its filing with the Commonwealth of Massachusetts Attorney General's Office.*
  3. Names and addresses of all Officers, Trustees or Directors of the organization.
  4. Project to be funded:
    1. Object of project
    2. Description of project
    3. Need for project
    4. Location
    5. How the project will accomplish its objectives and meet the need for it
    6. Duration of project - beginning and ending dates
    7. Budget for project:
      • List all position titles, such as Directors, Consultants, etc.
      • Give annual salaries. Percent applicable to project.
      • Materials, services, supplies (telephone, etc.), all equipment.
      • List travel and other items.
      • Total budget ($).
  5. Three bank and/or other references.*
  6. Copies of the two (2) most recent annual financial statements and details of total current income (including sources and expenses for the latest year).
  7. Indicate the amount of support for the proposed project from other sources, and whether a request has been submitted to any other agency or organization to fund this project.
  8. How will the awarding of this grant request serve the purposes of the Foundation in enhancing the health and welfare of the inhabitants of Barnstable County.
  9. Have you applied for funding from the Kelley Foundation within the last three years? If so, please give a brief summary of the project and results.

* Include one copy with the original grant request only. Additional copies of grant application, if requested, need not include this information.

The tax exemption status of this organization has not been altered or revoked, nor is such alteration or revocation contemplated to the best of my knowledge and belief. At the end of the period for which funds are requested, this organization agrees to file a report to include the following:
·Certified detailed report of expenditures from grant
·Detailed statement of accomplishments in relation to the purposes set forth in Paragraph 4(a)

The Foundation reserves the right to publicize information concerning any grant which may be awarded and to submit copies of this application to other foundations which may be considering the possibility of awarding funds to the applicant.

SIGNED UNDER PAIN AND PENALTY OF PERJURY.

Chief Executive Officer/Applicant

WHEN COMPLETED, THIS GRANT APPLICATION SHOULD BE MAILED TO:

Henry L. Murphy, Jr., Administrative Manager
Edward Bangs Kelley and Elza Kelley Foundation, Inc.
243 South Street, P. O. Drawer M
Hyannis, MA 02601