AgriBank - Grant Fund

Applicant Information

Legal Business Name

Headquarters Address

City

State

Zip

Business Phone

Mobile

Contact Name

Title

E-Mail Address

Business Type (enter one):

Fed ID # or SS #

Gross Income: $

Total Assets: $ Total Liabilities $

Project Information

Name of Project

Project location (Include name of location and street address)

Brief description of project; benefits of project, community needs that the project will meet; funding and support from others in community, project schedule

Number of people expected to be positively impacted

Description of geographic area expected to be positively impacted

Financial Needs and Resources
Grant Request Amount	$
Funding from other sources (describe sources):	$
Total expected income (describe sources):	$
Total expected expenses (describe items):	$
Please describe how the mineral exploration in western ND has adversely impacted your organization in your area

Any additional information or comments

Applicant Representations
Applicant signing below warrants that the information provided to the Rural Community Grant Fund and its administrators and agents (collectively "RCGF") or in connection with this application is true and correct, and authorizes the release of such information to RCGF. Applicant consents to RCGF obtaining a credit report or criminal history report or any other information relating to Applicant's financial information or background. Applicant releases all claims against RCGF for all acts or omissions which occur in verifying the above information. Any person is hereby authorized to provide such information as requested by RCGF. RCGF gives priority to applications made by nonprofit organizations qualified under IRS section 501(c)(3). Each applicant awarded a grant must submit evidence of its tax-exempt status to RCGF prior to the distribution of any grant including but not limited to, a tax determination from the Internal Revenue Service. Applicant affirms expressly that it will use the grant funds in compliance with all applicable anti-terrorist financing and asset control laws, regulations, rules and executive orders, including but not limited to, the USA Patriot Act of 2001 and Executive Order 13224. Any violation of this representation is grounds for immediate termination of the grant and return of all funds advanced to the applicant. If the award is granted, Applicant agrees to participate in public service announcements, media interviews, or video news releases. If the award is granted, Applicant agrees to provide periodic financial reports detailing use of the funds by the organization and project status. This report will generally include a listing of all expenditures from grant funds as well as an overall organizational financial report covering revenue and expenses, assets, and liabilities. When favorable action is not taken on an application, the Applicant will be notified in writing by RCGF of the denial, however Applicant understands RCGF is under no obligation to explain why the grant was not made and that there are no appeal rights.
Authorized Signatures: Corporation or LLC (Officer) Partnership(General Partner) Sole Proprietorship(Owner)

Name of Entity:		Individually:
By:
Title:		Date:
For use only by RCGF: Application Number Project type Cost center Receipt date Amount granted $ Decision date

Additional information in support of application request $10,000-$50,000

Please complete each field below

Applicant Name:

Budgeted project costs, including five-year proforma forecast:

Project schedule/action plan and deliverable dates to project completion:

Likelihood of project short term and long term success (with reasoning):

Please describe and attach a current balance sheet with supporting schedules or other documentation indicating Applicant's financial strength:

Bank reference and contact information:

Attachments:

Please note: File size limit of 10MB