Please type or print your answers on this form and include it with your cover letter and additional information.




DATE:  _____________________________            AMOUNT REQUESTED:  _____________



Organization Name:  ____________________________________________________________



Date Established:  ______________________________________


Address:_________________________________City:____________________ State:  ______ Zip________


Contact Name:______________________________ Phone No.________________ Fax No: _____________


Annual budget of your organization:  __________________________


Number of employees last year:  ______________________________


Geographical area served by organization: ___________________________________________


Are you a United Way agency?         Yes      No


Are you a government agency?          Yes      No


Specify which of the following services you offer:

Arts/Humanities                     Environment

Children/Youth                       Recreation

Health & Medicine                 Elder Care

Education                                Social Welfare



List the members of your governing board:







  • Copy of tax determination letter from Internal Revenue Service showing name of organization, tax identification number, and type of tax-exempt organization: Attached Not available


  • Attach Annual Report for last year: Attached                     Not available



Limited to 501(c)(3) organizations located within the following counties:  Bibb, Fayette, Greene, Hale, Pickens, Lamar, Marengo, Sumter and Tuscaloosa. 



Need for the Project:










  Project Description:










  Project goals and anticipated outcomes:









  • Application submitted by: _______________________________________




Print Name












Application Deadlines are October 1 and April 1


Target Amount of Grant $1500.00

Grants for increased amounts will be given consideration