Clay Buchholz Foundation • 10960 Wilshire Boulevard Fifth Floor Los Angeles, CA 90024

APPLICATION FOR FUNDING

Thank you for your interest in the Clay Buchholz Foundation. To apply for a contribution, please complete this form and return it to us with the attachments indicated. All information is required for consideration of any request. Please note that the Clay Buchholz Foundation does not consider requests for capital campaigns, administrative or personnel stipends or construction expenses. For more information, please visit our website at www.claybuchholzfoundation.org.

Part One:

Organizational Information

Organization Name

Address

Executive Director

Contact Person Name and Title (if different from executive director)

Phone Number Fax Number

Email

Website

IRS Tax Exempt Number

In order to process this request, a copy of the organization’s IRS letter of documentation stating that it isnonprofit and tax-exempt under section 501(c)(3) of the Internal Revenue Service must be attached.

Part Two: Financial Infomation

Total Board-Approved Annual Budget Fiscal Year-End

Indicate your organization’s major sources of funding (for example private donations, foundations, United Way, membership dues, fees and grants) for the past fiscal year.

Source Amount PercentofRevenue

(use additional sheet if necessary)

Please attach:• List of your organization’s current officers and board of directors, including their affiliations.• Brief description of your organization’s history, goals and key achievements• Copy of your organization’s two most recent audited financial statements

APPLICATION FOR FUNDING

The Clay Buchholz Foundation is a registered trademark and may not be used without the expressed written consent of the Clay Buchholz Foundation.

APPLICATION FOR FUNDING

Part Three: Program/Service Information

Attach a brief description (one page or less) of the goals and objectives of your program and why it needs to be funded. The summary should explain an overall description of your organization and how it meets these objectives and how these accomplishments meet community needs.

How long has your organization been in operation?

Are there services that are similar in your area for which you are seeking funds?

How will funds from this grant be utilized?

Who and how many will benefit?

What need does this grant address?

Total program budget (please attach an one-page itemized program budget)

Amount requested from the Clay Buchholz Foundation: $

How many staff members support your organization?

How many volunteers?

Attachments:All of the following must accompany your proposal:1. Brief description of your program2. IRS letter confirming tax-exempt status as a 501(c)(3) organization3. Current officer and board of director list4. Total board approved organizational itemized budget for fiscal year5. Two most recent audited financial statements6. List of companies and foundations being approached for funding

Executive’s Signature Title Date

Please submit this application to:Clay Buchholz Foundation

10960 Wilshire Boulevard • Fifth Floor • Los Angeles, CA 90024Phone: 310.722.1590 Fax: 310.602.6209 Email: Lisa@ClayBuchholzFoundation.org

www.claybuchholzfoundation.org

The Clay Buchholz Foundation is registered as a tax-exempt nonprofit organization undersection 501(c)(3) of the Internal Revenue Service.