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THE CLOTHES LESS TRAVELED THRIFT SHOP, INC.
Mailing Address: PO Box 3434, Peachtree City, GA 30269_
ANNUAL GRANT APPLICATION Revised Dec 2015 A. Organization Information 1. Organization Name__________________________________________________________________ 2. Federal EIN _______________________website__________________________________________ 3. Address __________________________________________________________________________ 4. City, State, Zip _____________________________________________________________________ 5. Point of Contact __________________________________________Title______________________ *who will receive future official CLT correspondence if approved 6. Email __________________________________________________phone_____________________ 7. Person Completing App___________________________________ phone_____________________ CLT Grants are available as Annual Support Grants and Semi-­‐Annual Project Grants. This application is for Annual Support Grants ONLY. The postmark deadline for Annual Grants is February 1. Annual Grant Requests are considered ONLY in February and must be resubmitted each year. Annual Grant recipients will receive quarterly payments toward their Grant Award. Annual Grant Recipients MAY NOT apply for additional Semi-­‐Annual Project Grants during any calendar year in which they are receiving annual support, unless it is an emergency request for funding. Applications will only be accepted from 501(c)3 organizations LOCATED IN AND SERVING South Metro Atlanta counties including Fayette, Coweta, Clayton and Spalding and the South Fulton cities of College Park, East Point, Fairburn, Hapeville, Palmetto and Union City. Additional inquiries regarding CLT Grant Applications may be directed to [email protected] Mail complete application package to the mailing address above, postmarked no later than February 1st. You must include ALL of the following for consideration: § One (1) copy of your organization’s 501(c)3 tax-­‐exempt status letter from IRS. § One (1) copy of organization’s current Board of Directors listing current personal address and phone numbers for contact as deemed necessary by CLT. § One (1) copy of pages 1, 2, 7-­‐12 of your most recent filing of IRS Form 990 as well as One (1) copy of 990 -­‐ Schedule A, including attachments. NOTE-­‐ If the IRS Form 990 is not from the most recent year, you must include a detailed explanation. § Two (2) copies of organization’s most recent Annual Financial Report (If you are part of a State, Regional or National organization, include detailed financial report for your LOCAL OPERATION ONLY) § Two (2) copies of your Projected Annual Budget § Three (3) copies of this completed Application form, one with original signatures CLT ANNUAL GRANT APPLICATION -­‐ Page 1 of 4 Revised Dec 2015 B. Organization Funding 1. Funding Sources: % of Annual Income* List __________________ __________________ _______________________________
_______________________________ __________________ _______________________________ -­‐ Organizations (other than govt.) __________________ _______________________________ -­‐ Individual Donors -­‐ Corporate Donors -­‐ Grants (including CLT) -­‐ Government Agencies (Medicare, __________________ _______________________________ Medicaid, State, County, etc.) -­‐Other __________________ __________________ *Must total 100% _______________________________ _______________________________ C. Organization 1. Number of full-­‐time personnel ______________ Please list 3 highest paid positions in your organization with corresponding annual salary: _________________________________________________________________________________ _________________________________________________________________________________ 2. Number of part-­‐time personnel _____________ 3. Number of volunteers _____________________ 4. List of Counties Served_______________________________________________________________ 5. Explain your organization-­‐ including mission statement, organizational structure, significant achievements, areas of greatest need and examples of annual programming. You may enter “See attached”._______________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 6. Explain how you measure the success of your services and/or mission. ________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ CLT ANNUAL GRANT APPLICATION -­‐-­‐2 of 4 Revised Dec 2015 ANNUAL GRANT AMOUNT REQUESTED: $________________ D. Annual Support Explain in full detail exactly what CLT Grant funds will be used for: -­‐ General Operations Y / N $_________________________________________________________ _________________________________________________________________________________ -­‐ Administrative Costs Y / N $_________________________________________________________ _________________________________________________________________________________ -­‐ Specific Program Y / N $__________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ -­‐ Other (Please explain) Y / N $________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
E. TOTAL BUDGET-­‐ must be completed Total Annual Expenses: Total Annual Income: 1. Personnel $________________ 1. Individual Donors $_________________ 2. Program Services $________________ 2. Fees/Revenue $_________________ 3. Space/ Rental $________________ 3. Corporate Support $_________________ 4. Marketing/ $________________ 4. Government Support $_________________ Fundraising 5. Administrative $_______________ 5. Grants $_________________ 6. Other $________________ 6. Other Revenue $_________________ Explain Other: ______________________ Explain Other: ______________________________ __________________________________ __________________________________________ TOTAL ANNUAL EXPENSES: $_________________ TOTAL ANNUAL INCOME: $____________________ CLT ANNUAL GRANT APPLICATION -­‐ 3 of 4 Revised Dec 2015 F. ATTENTION – FOR LOCAL CHAPTERS OF NATIONAL ORGANIZATIONS If your organization is the Local Chapter of a National Organization, please attach all required information for your Local Chapter, including the year the Chapter was founded and Local Chapter Articles of Incorporation. Please sign below and mail with ALL required attachments to: The Clothes Less Traveled Thrift Shop Inc., PO Box 3434, Peachtree City, GA 30269 NOTE: Incomplete, hand-­‐delivered or late applications will not be considered. * I certify, to the best of my knowledge, that the information contained in this application is correct. 1. _____________________________________________ ___________________ Signature of Person Preparing Application Date _______________________________________ _________________________ (Printed Name) Title * I certify, to the best of my knowledge, that the information contained in this application is correct. 2. _____________________________________________ _____________________ Signature of Board Chairman, President of Organization Date __________________________________ ___________________________ (Printed Name) Title CLT INTERNAL USE ONLY DATE REVIEWED BY BOARD________ Approved ____Not Approved _____Notified ____________________ Notes___________________________________________________________________________________
_______________________________________________________________________________________ CLT ANNUAL GRANT APPLICATION -­‐ 4 of 4 Revised Dec 2015