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EL PASO
COUNTY PHYSICIANS FOUNDATION The information on this form is required to help the EPCP Foundation meet the requirements of the Internal Revenue Code. I. GENERAL INFORMATION Name of Organization: ___________________________________________________________________________Contact Person: _______________________________________________________________________________ Title ____________________________________________ Telephone: ( __ )_____________________________ Address of Principal Office: ______________________________________________________________________ Tax Identification Number:___________________ Does the IRS recognize you as a publicly supported charity?______ Are you recognized as a 501(c)(3) organization by the IRS?_____ Do you also have 509(a)(1), (2), or (3) status? _______ Please submit a copy of the ruling letter received from the IRS for your organization confirming such status. II. HISTORICAL INFORMATION Date of Establishment:_________________________________________________________________________Organization's mission statement, objectives, purpose: ________________________________________________ III. PROGRAM/PROJECT INFORMATION Specific amount of funds requested: ______________________________________________________________It is recommended that the following information will be of assistance to us in considering your request: 1. Why aren't other organizations now meeting this need, can they, will they? 2. How will this program differ from what is being done now, by others, and why is the difference important? 3. Is there a demonstrable need for this program? 4. Will there be a measurable improvement in the delivery of services if the venture is successful, will harm be done if it fails? 5. Will the development of this program add an undesirable financial burden to the community or state? 6. Why can't the program be carried out better elsewhere or by other persons? 7. Why is the time right for this endeavor? 8. What has been done to consult and cooperate with established agencies in the same or related fields? 9. Past success or failures of your organization. 10. What problems do you foresee in implementing your program? 11. Why are you qualified to conduct this program? 12. What long lasting results will come from it? 13. What valuable elements will continue after the requested grant period comes to an end?14. What important difference will result from the project's success? 15. Is this going to be a model? If so, how? 16. Specifically who or what will benefit? 17. Why will investing in this program improve/benefit our community more than any other way we can contribute? 18. How will you determine the degree to which objectives are met and methods are followed? Describe the specific program or project for which you are requesting funds: Show funds provided by other parties:______________________________ and funds you will provide: _________________________________. (A detailed budget would be helpful) Has the Board of Trustees of your organization approved this project? ___________________ Have they approved the submission of this request?_________________________________ WE MUST RECEIVE 5 COPIES OF THIS APPLICATION AND ALL SUPPORTING DOCUMENTS. A LIST OF YOUR BOARD OF DIRECTORS MUST ACCOMPANY THIS APPLICATION. The Foundation requires the organization to which a grant is made to report, in detail, how the funds have been expended, and to return to the Foundation any unexpended grant funds. A report of the expenditure of the funds must be made annually until the entire grant has been accounted for. Further use of a balance may be requested. Please be aware that you may be requested to submit any of the following: • the resumes and job descriptions of the individual's) administering the proposed project or program • a copy of last year's financial statement, preferably a complete audit • a detailed budget of the program or project submitted for funding January 31, 1992 Revised: July 14, 1992
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