2021 Grant Eligibility Form – Impact100 South Jersey

Today's Date

Organization Information

Organization Name *

Organization Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Contact Name *

First

Last

Title

Phone *

Email *

Email

Confirm Email

Organization's Tax ID Number. *

In which of our 4 counties is your organization headquartered? *

Which counties does your organization serve? *

Does your organization have a mission and/or programs and services that fit one of Impact100 SJ's 3 Focus Areas? *

Yes
No

Focus Areas are Women, Children & Families, Arts & Culture, Education

To which Focus Area will you be applying? (choose one) *

Women, Children & Families
Arts & Culture
Education

Is your organization's annual operating budget above $300,000 and below $5 Million? *

Yes
No

Are you a 501(c)3 tax-exempt organization that has filed an IRS Form 990 for each of the past 3 years? *

Yes
No

Do you have 3 full years of audited financial statements? *

Yes
No

In any of the past 3 years, has an independent accountant expressed any concerns regarding the organization’s financial health or viability? If yes, please explain. *

Yes
No

Explanation

Litigation/Liability: Is there litigation pending or threatened against your organization? Or is there a recent judgement? If yes, please provide details. *

Yes
No

Explanation

Document Upload (PDFs Only)

Please upload the following documents to our online platform. To protect the integrity of the information you provide, please upload PDFs of these documents.

Current fiscal year operating budget. *

Upload your Form 990 (Year 3). *

Upload your Form 990 (Year 2). *

Upload your Form 990 (Year 1). *

Upload your current fiscal year income statement (P&L). *

Upload your current fiscal year balance sheet. *

Upload your independent financial audit (Year 3). *

Upload your independent financial audit (Year 2). *

Upload your independent financial audit (Year 1). *

Most recent 501(c)(3) letter. *