2022 Grant Eligibility Application - Impact100 South Jersey

Today's Date

Organization Information

Organization Name *

Organization Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Information for CEO/President/Executive Director *

First

Last

Title

Phone *

Email *

Email

Confirm Email

In which county is your organization headquartered? *

Burlington County
Camden County
Gloucester County
Cumberland County

In which city/town is your organization headquartered? *

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, Community Health & Well-Being, Education

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

Yes
No

NOTE: We want to make sure your organization is large enough so that a $100,000 grant is not a huge percentage of your operating budget, but small enough so that a $100,000 grant makes a significant impact.

Is your organization a stand-alone 501(c)3? *

Yes
No

Has your organization filed an IRS Form 990 for each of the past 3 years? *

Yes
No

NOTE: We collect 3 years of form 990 because we use the data as part of our financial analysis of your organization.

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

Yes
No

NOTE: We collect 3 years of audits in order to ensure we have a more complete picture of your organization’s financial position.

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

If "yes" please explain.

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

Yes
No

NOTE: Your answer provides us with details used in our overall analysis of grant suitability.

Please provide details.

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.

Your organization’s current fiscal year operating budget *