HomeMy WebLinkAboutGrant Applic Form - RevDeschutes County Discretionary Grant Application
Deschutes County Board of Commissioners
1300 NW Wall St., Bend, OR 97701
(541) 322-7697 Fax (541) 385-3202
www.deschutes.org
APPLICANT INFORMATION
Organization Name Project Name
Street Address
City Zip Phone
Contact Name E-mail Address
Beginning Date End Date Date Funds Needed
Requested Amount Total Project Budget
TYPE OF REQUEST (SELECT ONE):
Funds for a capital purchase or the purchase or equipment Funds for a fundraising event
Funds for an event (not a fundraiser) Funds for staffing
Other (Please specify):
ORGANIZATIONAL INFORMATION
1. For an application to be considered by the Board of Commissioners, proof of the organization’s non-
profit status must be submitted with this application.
2. Describe the organization including the history, mission, leadership structure and primary functions
and activities (maximum 250 words).
3. Describe the program (project, activity or event) seeking grant funding. Include the specific
individuals, communities or groups benefiting from this program (maximum 250 words).
4. Itemize the anticipated expenditures for the program. Also, provide a list of anticipated sources of
funding and amounts projected.
5. Explain how this program will positively impact the community’s economic health (maximum 250
words).
6. Identify the outcomes the organization seeks to achieve through this program (maximum 250 words).
DISCLAIMER AND GRANT AGREEMENT
I certify that my answers are true and complete to the best of my knowledge.
If this application results in the receipt of a Deschutes County Discretionary Grant, I agree to the following:
The grant funds will be used only for the intended purpose, identified in #3 above.
The grantee will complete a project completion form within 30 days of expending grant funds. A failure
to return the project completion form will disqualify organizations from consideration for future
discretionary grant funding.
The grantee will make available its financial records to Deschutes County upon request.
Signature Date
BOARD OF COMMISSIONERS’ GRANT ALLOCATION
Tammy Baney Date Amount
Anthony DeBone Date Amount
Alan Unger Date Amount