Portsmouth Sunrise Rotary - Allocation Request Form

4. Purpose or mission of organization or project:_________________________________ _________________________________________________________________________

_________________________________________________________________________

5. Reason for fund request:___________________________________________________

_________________________________________________________________________

6. Amount requested: ________________ When needed: _________________________

7. Have you requested Rotary funding in the past? _________ If yes, when: __________

8. If this is your first fund request, please explain past funding sources:______________________

________________________________________________________________________________

9. Are you applying for funds from other sources in connection with this request? _________ If yes please identify name(s) of sources:____________________________________________________

_________________________________________________________________________________

10. Has your organization been determined by the IRS to be a Tax Exempt 501(c)(3) Non-Profit Organization? ______

A. Are you applying for funding through the use of a “conduit” or “pass through” IRC 501C(3)

organization: ___________ If so, do you have a written agreement with such organization to

“pass through” funds if awarded: __________

B. Please indicate percentage of requested funds to:

1. Your total annual operating budget: __________%

2. Your budget project costs: __________%

C. Please indicate level of financial statement: Audit ______, Review_______,

Compilation ______, Internally generated ______

D. Supplemental documentation (copies):

1. Supporting materials for request

2. Financial statements for the recent year

3. Annual report

4. List of current officers and trustees/directors.

11. Additional Comments:__________________________________________________________

________________________________________________________________________________

NOTES:

A. All grant requests will be subject to the review of a committee member which will ordinarily result in a visit and/or telephone conference with you to verify and seek additional information that may be required.

B. Please note that all grants awarded by the Rotary Allocations Committee in excess of $1,500 require follow-up monitoring by a committee member and documentation as to the actual grant utilization and/or applications.

C. Please print and complete the form on this page. Incomplete or missing form may result in no allocation being made to your organization.

D. Mail the completed form ALLOCATIONS COMMITTEE,

and supporting ROTARY CLUB OF PORTSMOUTH SUNRISE

documentation to: P.O. BOX 6674

PORTSMOUTH, NH 03802-6674