"Community Grant Application Form - Walmart"

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Application for Community Grant

Return completed form to the Wal-Mart Store or Sam’s Club where you obtained this application

Location Use Only

Location #: ___________

City: ___________________________

ST: _______

Type: WM / Sam’s / DC / TO _______________________

Amount Requested:

___________________

Managers Name (signed and printed): _____________________________________________________________________ Date: ___/___/________

Community Involvement Associate:

_____________________________________________________________________ Date: ___/___/________

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.

Organization Name: __________________________________________________________________________________________________________

Federal 501 (c) (3) Tax ID #:

___________________________ Public Charity Status:

509(a) (1)

509(a) (2)

(9 digits) _

Address: __________________________________________________ City: ______________________________ ST: _____ Zip: _______________

Contact Name: _____________________________________________ Contact Phone: _______-_______-____________

Specifically, how will funds from this grant be utilized in your local community?

___________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

What service does your organization provide to the community?

____________________________________________________________________________________________________________________________

Will these grant funds directly benefit your LOCAL community?

Yes

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.

Signed: ______________________________________________ Printed: ___________________________________________ Date: ___/___/______