print Home In The Community Health Partners Foundation Grant Application Grant Application Organization Name* Address Line 1* Address Line 2 City* State* (please select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code* Contact Name* Contact Phone* Contact Email* Federal 501(C)(3) Tax ID Number* In which of the HPF areas of focus does your proposed program fall?* (please select) Education Emergency Relief Anti-Violence Other If other, please describe Select the option that best describes your organization:* Tax exempt under Section 501(C)(3), (4), (6) or (19) of the Internal Revenue Code with a valid tax exempt number K-12 public/private school, charter school, community/junior college, state/private college or university Church or other faith-based organization with proposed projectsthat address and benefit the needs of the community at-larte Other If other, please describe Does your organization have an office in and provide services to constituents living within at least one of these counties: Adams, Berks, Bucks, Chester, Cumberland, Dauphin, Delaware, Franklin, Fulton, Huntingdon, Lancaster, Lebanon, Lehigh, Montgomery, Northampton, Perry, Philadelphia, or York? Yes Does your organization have a program that serves the elderly in at least one of these counties: Adams, Berks, Bucks, Chester, Cumberland, Dauphin, Delaware, Franklin, Fulton, Huntingdon, Lancaster, Lebanon, Lehigh, Montgomery, Northampton, Perry, Philadelphia, or York? Yes How many years has your organization been in operation?* Does your organization have at least one full-time equivalent (FTE) employee? Yes Can you provide an audit or IRS Form 990 for the years your organization has been in operation (up to the past 3 years)? Yes Does your organization re-grant the funding it receives? Yes Has your organization previously received funds from the Health Partners Foundation? 2016 Amount 2015 Amount 2014 Amount Please tell us the type of donation you are requesting: Monetary donation or sponsorship Amount $ In-kind donation. Items, etc. Date needed: Please describe how the funds will be used: Submit Organizations will be notified electronically regarding the status of the grant request.