Revised 7/27/2019

The Canal Society of Ohio, Inc.
9845 North Hardin Road, Piqua, OH 45356
www.canalsocietyohio.org

Grant Application Form
Submission deadline: last day of September
See instructions page and checklist before completing the application

Name of Organization 
Street address:                                   
City/State/Zip:                                   
Contact person:                     
Daytime Phone:                                              Email: 

Internal Revenue Service status 501(c)(3) or equivalent? Yes__ No__ Federal ID#        
Organization’s objective and history (briefly stated including major activities and length of time in business)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
   
This space must be used to briefly state purpose for grant (you may attach a separate page if further explanation is needed):
_________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________   
Area(s) of Ohio served by project:
Number of Ohio residents affected by project:
Amount requested:                   (rounded to nearest dollar)   Total project budget:
Other sources contacted for support of this project and amounts: 


Organization’s history with The Canal Society of Ohio, Inc.:
First Grant Request? __Yes  __ No  Date of Last Request:           Date Last Grant Awarded:
 

THE FOLLOWING SIGNATURES ARE REQUIRED:
I certify the information is accurate to the best of my knowledge and 5 sets of this application along with the documents listed below have been included.
CEO/Director_________________________ Signature____________________________Date_______
President/Chair_______________________ Signature____________________________Date_______ 

• grant application form (prefer application be typed)
• basic budget statement for the proposed project or purchase
• most recent financial statement
• organization’s annual report or equivalent
• List of Governing Board members
• Submit 1 copy of the organization’s letter of determination from the Internal Revenue

• Service  certifying 501(c)(3) status or equivalent.                                                                                                           

CHECKLIST
Make certain to complete the grant application in its entirety and submit prior to the deadline.  Applications that are incomplete or missing required supporting documents will not be accepted.  Before submitting the application use the following checklist:
____All required signatures are on the application
____A dollar amount requested for the grant and total project cost is noted on the application 
____Application must include:
            Completed grant application form (prefer application be typed)
            Basic budget statement for the proposed project or purchase
            Most recent financial statement
            Organization’s annual report or equivalent
            List of Governing Board members

____1 copy of the organization’s letter of determination from the Internal Revenue Service certifying 501(c)(3) status or equivalent.  This is an actual letter from the IRS, not from the State of Ohio or a certificate.  If you cannot locate your letter from the IRS, contact them at 1-877-829-5500.  Provide them with your organization’s tax identification number and a copy of your letter can be mailed or faxed to you.  Do not wait until the last minute to obtain a copy of this letter.  Your application will not be accepted if the letter is not included with the application prior to the deadline.

____If mailing, use the United States Postal Service. The office is not staffed full time to accept deliveries from other carriers.