Please note. All applications will be carefully reviewed. However, by completing this form, there is no guarantee that your request will be granted.
CITY OF Bass'Ken Lake
Page 1 of 5
Request for (Circle One):
[ ] Items
[ ] Gold Donation
Please note:
Normal service request procedures should be followed for standard services.
DATE: ________________
Date of Event: _______________________
Please complete the following and submit to:
walawala.walawala
City of Bass'Ken Lake
1 Bass'Ken Lake
Barton Town, Gaia
1. Proposed Project/Questing Item Name
2. Requested Funding Amount: $
3. Have matching funds been secured for this project? [ ]Yes / [ ] No
4. Applicant Information:
Name of Organization/Agency:
Contact Name:
Mailing Address:
Street Address:
City
State
Zip
Email Address
Telephone
Fax
Business License #
Nonprofit ID #
(attach copy)
5. Does this project/questing item fall under one or more of the Gaia City Development Goals? If yes, please explain:
6. Have you or your organization previously requested and/or
received any funding from anyone? If yes, please provide any
pertinent funding information (listing for each donation):
7. Will promotional materials be created for this project / item ?
[ ] Yes / [ ] No
Page 2 of 5
CITY OF Bass'Ken Lake
Request for:
[ ] Items
[ ] Gold Donation
Date: _____________________
8. Proposed Project Information:
a. How will the requested funds be used? Describe, in detail, the proposed project / questing times. Clearly define any fee schedules that are applicable to this project. Identify if the proposed project is a new service, or extension of an existing one.
____________________________________________________________________________
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____________________________________________________________________________
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____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
b. Specify the proposed area (i.e., Gaia town), population or agency that will benefit from this program or project or item(s).
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
c. What documentation/data/records support the need for this proposed project? Identify your data sources. Additional pages may be included, if needed.
____________________________________________________________________________
____________________________________________________________________________
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Page 3 of 5
CITY OF Bass'Ken Lake
Request for:
[ ] Items
[ ] Gold Donation
Date: ______________________
Required Attachments:
Please provide the required copies of the following: (Please note: Applications without the following documents will not be reviewed for funding) Please label attachments A, B, etc.
A. Names and home addresses of governing board; identify current board officers, etc. Homes addresses are required.
B. Personnel Information
i. List of all paid positions by classification and salary scale. If classification is part-time or temporary, indicate percentage of time on an annualized basis.
ii. Identify contract services (bookkeeping, answering service, secretarial, etc.) and total cost per contract on an annual basis.
C. Proof of Non-Profit 501(c) (3) or (c) (6)
D. Proof of insurance.
Signatures:
Applicant
Date
Name of Organization / Agency
Note: Applicants will be notified within fourteen (14) business days if the request for use of City
Funds will be granted.
=======================================================
For Barton Town Use
Approved by: ___________________________________________________________
Director Signature
Date
Charge to: _________________________
Budgeted in Current FY? [ ]Yes / [ ]No
Account Number
Total Fees Waived: $ ___________________________
Page 4 of 5
Barton Town
Note: Approval of donation requests requires an accompanying check request.
FINAL Report and Reimbursement Form
Fiscal Year __________
THIS IS A MANDATORY FINAL REPORT
This report encompasses project activity, plus provides an overall project summary. The form
should be completed and mailed to:
_________________________
Barton Town
1 Barton Town
Barton Town, Gaia
Date Received: __________________
Application Number: _________________
Name of Agency/Organization:
Address:
Project Name:
Please recap your event or program including as much detail as possible relating to its outcome, specifically the number of people who attended, fees collected, funds disbursed and any goals/objectives that were reached as a result of the program. Please use a separate sheet of paper, if necessary.
Contact:
Report Prepared by:
Telephone Number:
Email:
Amount of Grant Awarded:
Total Amount Invoiced:
If funds have not been used to date or project not implemented – sign and return cover page only at this time.
__________________________________ _______________________________________
Signature
Date
Page 5 of 5
Barton Town
Request for Fee Waiver and/or Fee Reduction / Donation
Final Report
Fiscal Year __________
Schedule A
Project Proceeds and Expenditures Summary
GROSS PROCEEDS FROM EVENT
$
EVENT EXPENDITURES
Salaries
Consultant Fees
Equipment
Supplies/Materials
Promotion/Publicity
Travel/Transportation
Other : If you follow this form
up to this point , I believe you
are serious...
TOTAL EXPENDITURES
$
NET PROCEEDS FROM EVENT
$
CITY FEE WAIVER/DONATION AMOUNT GRANTED
$
(reference: City of Brentwood Request for Donation Application )
