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Building Healthy Communities Application

Date

Name of organization:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email:

Phone:

Contact name and position:

Purpose and mission of the requesting group:

Which of the approved categories best fits your request?

Number of members in your organization:

Tax ID Number:

Upload letter from IRS indicating Section 501(c)(3) tax-exempt status:

One file only.
10 MB limit.
Allowed types: pdf.

Current financial statements, including a balance sheet and statement of income and expenses within the last 12 months:

One file only.
10 MB limit.
Allowed types: pdf.

An income tax return for most recent fiscal year preceding the applicable grant application:

One file only.
10 MB limit.
Allowed types: pdf.

A current copy of your organization's W9 document:

One file only.
10 MB limit.
Allowed types: pdf.

Have you received funding from Duke Health in the past?

Yes

No

If yes, how much much was received?

Description of prior event/initiative

If you were funded last year and seek funding this year, attach an itemized list of how the funding was used:

One file only.
10 MB limit.
Allowed types: pdf.

Organization's most recent annual report:

One file only.
10 MB limit.
Allowed types: pdf.

Description of initiative/event (purpose, target audience, how often it will be held, recognition for Duke Health):

Date of event/initiative:

What is the amount requested?

What percentage of your budget is this request?

By what date is a funding decision needed?

What are the expected or intended results from use of donated funds?

If Duke Health should support the organization/event, would it be the exclusive health care supporter?

Yes

No

Description of recognition and other benefits Duke Health will receive:

List any current relationships your organization has with Duke Health:

Names of any Duke Health representatives on your board:

Are you asking another Duke Health affiliated entity, division, or department for funding?

If so, who?

How will funding this request help Duke Health further its mission?

Executed on behalf of the applicant by:

Print name:

Title:

Once your application has been submitted you will receive an email with your completed submission. Please save this email to your files for reference.