Matching Funds Request Form | Rice Lake Community Health Foundation

* Attention: if this application is not fully completed the application will not be accepted.

Charitable Organization

Charitable Organization Name *

For Profit/Not For Profit? *

For Profit

Not For Profit

Tax ID# *

We need every organization who requests money to attach the documents below along with this application:
1) The Budget for the year
2) The Profit and Loss Statement
3) The Balance Sheet

Salaries for top two individuals/employees:

Top Salary #1 *

($ amount in USD)

Top Salary #2 *

($ amount in USD)

Please relate your charity’s mission: *

How many years has your charitable organization been functioning? Please provide the following information:

Years of service: *

Overhead as a percentage of contributions: *

Upcoming or ongoing fundraising events: *

Goals and objectives for the funding year: *

(note that a new funding year begins every September 1st)

Who are your constituents and what health related services do you provide? Provide us a brief description of how the distribution of services to your target mission recipients takes place. *

How much funding comes from private & government funding? *

Funding Request

What amount of matching funding are you seeking? *

($ amount in USD)

If selected to receive matching funds how will they be used? *

(note that the Foundation can not provide funds for direct operating overhead)

Requestor's Contact Information

Name *

Title *

Phone Number *

E-mail Address *

Supporting Files

We need every organization who requests money to attach the documents below along with this application:
1) The Budget for the year
2) The Profit and Loss Statement
3) The Balance Sheet

We welcome any additional information about your organization. Please feel free to attach it below.

*Alternatively, you may send an email with your documents attached to: BillieJo Peterson at swansonbi@mosaictelecom.net

File 1:

Maximum upload size: 2.1MB

File 2:

Maximum upload size: 2.1MB

File 3:

Maximum upload size: 2.1MB

File 4:

Maximum upload size: 2.1MB

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