PURPOSE:  For use by non-profit organizations in the Wheeling-Ohio County area that are seeking grants for program support.  Please note that grants that support vision-related projects or those programs benefiting children and senior citizens will receive special consideration.

INSTRUCTIONS:  Applicants are encouraged to submit only this form for consideration.  Applications may be typed or neatly hand written, and this form is available on diskette in Microsoft Word format for electronic application.  Complete each section of the application in the space provided and be as concise as possible.  NOTE: Applications without a contact name or tax ID number will not be reviewed.

Upon completion, please provide 6 photocopies of your grant plus the original and mail them to the Distribution Committee, Wheeling Lions Club, P.O. Box 1122, Wheeling, WV  26003.  Please allow 6-8 weeks for a response.
 
 

Legal Name and mailing address of civic or non-profit organization submitting application as listed with the West Virginia Secretary of State: _________________________________________________________________

                             _________________________________________________________________

                             _________________________________________________________________

Tax Exempt ID Number: ___________________________________________________
 

Location where project will take place: _________________________________________
 

Contact Information:

 Name: ____________________________________________________________

 Phone: ____________________________     Fax: _________________________

 E-mail: ___________________________________________________________
 

Other charity involved with project, if any: ____________________________________
 

1. TOTAL PROJECT COST: $________________________

2. AMOUNT REQUESTED FROM WHEELING LIONS: $____________________

3. SPECIFIC PURPOSE FOR WHICH FUNDS ARE BEING SOUGHT:
 
 
 
 
 
 
 
 
 

4. INTRODUCTION – Give a brief description of the organization seeking funds:
 
 
 
 
 
 
 
 
 
 

5. PROBLEMS, OBJECTIVES, METHODS – Give a brief description of the basic need; describe what it is you want
accomplish and methods you plan to use:
 
 
 
 
 
 
 
 

6. TIMING – List the date(s) or time frame for the project.  Give its current status, indicating how long it will take to finish and whether there are later stages.
 
 
 
 

7. COST AND FINANCING – List the principal cost elements of the project.
 
 
 
 
 
 
 
 

What funds have already been obtained?  List sources, including other foundations.  How much has been raised locally or from your own constituency?
 
 
 

 When will this project be self-supporting?

8. EVALUATION – Explain how you are going to determine that you have accomplished what you want to do.
 
 
 
 
 
 
 
 

9. a. FINANCIAL INFORMATION – Please attach one copy of your most recent financial statement or balance
        sheet (audited, if available).

     b.  IRS FORM 990 – Please include your most recently submitted return
          (if applicable).
 
 

_________________________________       _____________________      __________
Signature of Applicant                                        Title                                         Date

ACTION TAKEN BY: ____________________________________________________

 APPROVED                                   DATE: ___________  AMOUNT: _______________

NOT APPROVED                           DATE: ___________  FOLLOW UP BY: __________