CHURCH MOUSE GRANT APPLICATION

The Church Mouse Thrift Shop, Inc.
5457 Big Tyler Road * Cross Lanes, WV 25313 * 681-217-2008

2020 Grant Application

Name of Organization, Group or Individual: ______________________________________________________
Mailing Address: ___________________________________________________________________________
Physical Address: ___________________________________________________________________________
Phone #: _______________________________________ Fax #: _____________________________________
Contact Person and Title: __________________________ Email: ____________________________________
Mission Statement:__________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Amount Requested: _____________________________________
Describe purpose for which funds will be used: ___________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Other sources of income and recently received grants (list all organizations including federal, state, county and local funds): _______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________
Application completed by (print name and title):___________________________________________________
Signature: ____________________________________________ Date: ________________________________
OTHER REQUIRED DOCUMENTATION TO BE PROVIDED
*Proof of federal income tax exemption status (501C3 organization) or EIN number
*Financial statement for prior fiscal year to include actual income received and expenses (P&L and BS)
*Budget and financials for current fiscal year
*List of current Board of Trustees/Directors and Principal Officers of organization requesting grant

APPLICATIONS MUST BE MAILED TO THE CHURCH MOUSE THRIFT SHOP, c/o Cross Lanes United Methodist Church, 5320 Frontier Drive, Cross Lanes, WV 25313.

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