Organization name: (hereinafter “Applicant”)
Applicant hereby gives written assurance that:
1) The activities and services for which assistance is sought will be administered by or under the supervision of the Applicant.
2) Funds received under this application will be used only for the specific Project listed in the Grant Request and not for any political purpose.
3) The filing of this request has been authorized by the Board of Directors of the Applicant.
4) The requesting organization is recognized by the IRS as a qualified tax-exempt, non-profit organization I.R.C. 501 (c)(3) or similar provision.
5) Funds received under this application will be used primarily for charitable organizations, activities, operations, or purposes within the State of Maine or for the benefit of Maine residents.
6) Any changes in proposed Projects, including but not limited to the termination of the Project, receipt of other funds which eliminate the need for the grant requested herein for the originally stated Project, or anticipated delay of the Project for more than twelve months, will be noted and sent to the Simmons Foundation for further review before any expenditure of grant funds.
7) A brief review and/or final evaluation of the use of the grant for the stated Project, including, if applicable, the goals obtained and success of the Project, will be sent to the Simmons Foundation within six months of the use of the funds or the termination of the project.
I, , do attest that the information contained in this application and in any attachments made as part of this application, are true and correct to the best of my knowledge.
Signature of authorized representative:
Title:
Date:
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