This application must be completed and kept on file for record retention of three years at your location
To be completed by the Organization:
Select one:
IRS designated
501 (c) (3)* organization
OR:
Public School
Federal, State or Local Government Agency
*Organizations with current tax-exempt status under Section 501(c) (3) of the Internal Revenue Service Code and that are also public charities under Section 509(a)(1) or
509(a)(2). *Organizations must be listed in the most current IRS 50 State Master File at the time of application.
Will these grant funds directly benefit your LOCAL community?
Yes
No
Which of the following groups will this funding primarily benefit? This information is used solely to track our funding to specific diverse community groups and is NOT considered during the
grant review or approval process.
Please select only the most appropriate:
Hispanic
African American
Asian American
Native American
Caucasian
General Population (benefits the entire community)
Organization Representative:
By signing below I acknowledge that this form represents a request for funding, and is not a guarantee of funding. Final approval is subject to the guidelines
of the Wal-Mart Foundation. All organizations requesting grant funding must abide by the rules and guidelines set forth by the location, Wal-Mart Stores, Inc., and the Wal-Mart Foundation. This
request will not be processed unless completed and signed by all parties.
This application must be completed and kept on file for record retention of three years at your location
To be completed by the Organization:
Select one:
IRS designated
501 (c) (3)* organization
OR:
Public School
Federal, State or Local Government Agency
*Organizations with current tax-exempt status under Section 501(c) (3) of the Internal Revenue Service Code and that are also public charities under Section 509(a)(1) or
509(a)(2). *Organizations must be listed in the most current IRS 50 State Master File at the time of application.
Will these grant funds directly benefit your LOCAL community?
Yes
No
Which of the following groups will this funding primarily benefit? This information is used solely to track our funding to specific diverse community groups and is NOT considered during the
grant review or approval process.
Please select only the most appropriate:
Hispanic
African American
Asian American
Native American
Caucasian
General Population (benefits the entire community)
Organization Representative:
By signing below I acknowledge that this form represents a request for funding, and is not a guarantee of funding. Final approval is subject to the guidelines
of the Wal-Mart Foundation. All organizations requesting grant funding must abide by the rules and guidelines set forth by the location, Wal-Mart Stores, Inc., and the Wal-Mart Foundation. This
request will not be processed unless completed and signed by all parties.
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