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2. Agency Name*
4. Address*
6. City*
7. State*
8. Zip Code*
10. Phone Number*
11. Email Address*
13. Contact Name and Title*
15. Brief Description of Organization/Agency Mission (50 words or less)*
19. Has anyone associated with the agency/organization within the last five years been accused of malfeasance misuse of agency funds?*

    1. Yes
    2. No
20. If yes, please add a letter of explanation to this application.
22. Type of Application*

    1. 501(c)(3)
    2. Other
23. Category of Application*

    1. Category 1 (Your proposal meets a public need of the residents of Boone that is not addressed by Town of Boone services.)
    2. Category 2 (Your proposal supplements an existing service provided for by the Town of Boone or implements an identified goal established by the Town Council.)
27. Did your agency receive funding from the Town of Boone in 2022/2023?*

    1. Yes
    2. No
28. If yes, did you file a 2022/2023 follow-up report?

    1. Yes
    2. No
30. Did your agency receive in-kind services from the Town of Boone in 2022/2023? *

    1. Yes
    2. No
31. If yes, please list
33. Amount of all funds in 2022/2023 allocated from all Town of Boone sources*
35. Amount of Funding Requested for 2023/2024*
37. Amount of 2023/2024 Estimated Total Agency Budget Income*
39. Amount Requested from the Town of Boone is what percentage of your total budget?*
41. Please upload any additional lists or statements here

    If uploading a file, please label the top right hand corner of the first page of the file #1

43. Only COMPLETE applications will be eligible for outside agency funding. Applications will be reviewed for completion by a designated Town staff member. Applicants will be notified if their application is incomplete. Those that are incomplete will have the opportunity to submit the remaining materials necessary in order for the application to be considered complete by the deadline of April 29, 2023. Should you have any questions, please contact Town Hall at 828-268-6200.  

    
    

    *If your organization received funding from the Town of Boone in FY 2022/23, please submit a narrative of no more than three pages to address items 2-6, 9 & 10, an account balance sheet, a list of current Board of Directors and a 990 Form. 

    *If your organization did NOT receive funding from the Town of Boone in FY 2022/23, please submit all documents requested below. 

    
    

    At the top, right corner of each page, please number the materials submitted according to the numbers listed below and submit in order. 

47. 2. A 1-page or less explanation of how the funds requested will meet a public need of the residents of Boone OR a 1-page or less explanation of how the funds requested will supplement an existing service provided for by the Town of Boone or implements an identified goal established by the Town Council. *
49. 3. A 1-page or less explanation of whether your organization’s mission or services are duplicated by another organization(s) and if so, how coordination of services occurs.*
51. 4. A 1-page or less explanation of the measurable goals or outcomes and implementation plan including timeframes for the use of the funds. *
53. 5. A 1-page or less description of the population served by the requested funds including the total number served. Also include an explanation of the percentage of this population that is Town of Boone residents or how the population served is beneficial to the Town of Boone. *
55. 6. A 1-page or less statement indicating your program service expenses versus all other expenses (management, fundraising and general expenses). *
57. 7. A copy of your current budget with a statement of anticipated changes for the upcoming year. *
59. 8. Last 12 months P & L Statement. *
61. 9. Balance Sheet including an explanation for any reserves held by the organization. *
63. 10. Copy of your most recent 990 form, if applicable. If not required, please attach a written explaination. *
65. 11. Previous year audit report and all management letters for the most recent year, if applicable. If your organization does not require an audit report, please provide for your most recent operating year (calendar or fiscal) a sworn statement of account for all receipts and expenditures or a certification statement by the Board of Director’s Treasurer stating the organization’s accounting system is adequate and sufficient to manage Town of Boone funds.
67. 12. List of Board of Directors including terms of office, officer assignments and a statement confirming the composition of the current Board of Directors meets the organization’s bylaw requirements and an explanation if it does not. *
69. 13. Certificate authenticating non-profit status. *
71. 14. Current NC solicitation license, if applicable. If not required, please attach a written explanation.*
73. If any of the above items are not included in your application, please attach a written explanation.

75. I have the authority and hereby certify that the information contained in this application and the accompanying documents are true, that all financial documents have been reviewed for accuracy, and that the application is made with the knowledge and proper authorization of the organization. 

77. Name*
78. Title*
80. Electronic Signature*
81. Date Signed*
    Date Signed
83. Electronic Signature Agreement

    By signing above, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

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85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit

* indicates a required field