Application for The Neyer Foundation Grant

Please print this document and use it as a guide to fully complete each of the questions below for consideration in receiving a Neyer Foundation grant.  You may use additional pages as necessary.

Mail your completed application to:

The Neyer Foundation
302 W. 3rd Street, Suite 800
Cincinnati, Ohio 45202

Or email it as a Word document attachment to ldoherty@neyer.com

1. A. Name of Organization:

    B. Address:

    C. Telephone No.: Fax No.:

    D. Website (if any):

    E. Amount of Grant Requested:

2. Date organization established and affiliation(s):

3. Names of organization's administrative officers. Names and addresses of governing Board of Organization:

4. Attach U.S. Internal Revenue Service Certification of 501(c)(3) status:

5. Attach "Articles of Organization" or similar organizational charter, if applicable:

6. Provide a detailed description of the history, purpose and activities of the organization. This should also include a description of the services provided, to whom they are provided, how many are served per year, geographic area served, and whether any other organization in the area serves a similar purpose:

7. Describe the intended use of this grant:

8. Provide the budget for the project, other sources contacted for support, amounts requested from each, and any grants received:

9. Plans for permanent funding, if project is of a continuing nature:

10. Timetable for completion of project and expenditure of grant:

11. Attach applicant organization's latest balance sheet and annual operating statement, showing income and expenses in detail, including percentage of budget received from United Way, Federal or State funding, and/or other sources. Include percentage of costs paid by program recipients:

12. Date of your most recent prior grant, if any, from the Neyer Foundation:

13. Indicate which of The Neyer Foundation categories (on page 1 of this application) this project most appropriately fits and why:

TERMS OF GRANT AGREEMENT
FOR NEYER FOUNDATION

1. Applicant agrees that any grant received from The Neyer Foundation will be expended for the explicit purposes described in the grant proposal. In the event grant monies are to be allocated for any other purpose, agreement must be obtained from the Foundation Trustees.

2. Applicant agrees, following expenditure of any grant received, to return a follow-up report to The Neyer Foundation. An itemized budget is part of this report.

I, the undersigned, have read and understand the Terms of Grant Agreement, and, should a grant be received, agree to follow its terms and conditions.

 _____________________________________
  Applicant Agency

 By: __________________________________
  Signature

 Title:_________________________________

 ____________
         Date