HomeMy WebLinkAboutSpay and Neuter Grant ApplicationDeschutes County Spay and Neuter Grant Application
Complete this application form and return it, along with a letter from the IRS granting your
organization 501(c)(3) tax-exempt status, to the following address:
Dave Inbody
Deschutes County
Department of Administrative Services
1300 NW Wall Street, Suite 200
Bend, Oregon 97701
Applications may also be sent via e-mail to davidi@deschutes.org. All documentation must be
received by November 1, 2008. Any applications that have not completed all requested
documentation will not be considered. No information or materials in addition to that specifically
requested in this application will be considered.
Contact Information
Organization Name _____________________________________________________________
Address ______________________________________________________________________
City ________________________ Zip Code ____________
Phone Number __________________ Alternate Phone Number _______________
Fax Number ____________________ E-Mail Address _____________________
Website ___________________________
I certify that the all information provided to Deschutes County is correct and that I am authorized by
the governing board of this organization to submit this grant application. Further, I certify that this
organization is in good standing with the IRS and retains its official 501(c)(3) tax-exempt status.
Additionally, I certify that this organization is located in Deschutes County and any proceed from this
grant will be used in support of Deschutes County residents.
Print Name ___________________________________________
Signature ____________________________________________
Title _________________________________________________
Date _____________________
Organizational Information
Briefly describe the history of your organization (max 150 words):
Mission of your organization
Describe the leadership and structure of your organization. If there is a board, include the
names of its members (max 100 words)
Briefly describe the primary activities conducted by your organization (max 150 words)
Financial Information
Period covered by the most recently completed fiscal year _________________________
Total expenditures for this period _________________________
Total financial support received for this period _________________________
Project/Program Information
Describe the specific program or project that this grant will support (max 150 words)
Describe how this program or project will positively impact the goal of promoting or
expanding spay and neuter services (max 100 words)
Explain the anticipated outcomes of this project or program and describe how success
will be measured (max 100 words)