Masonic Charities of Arizona

Grant Application

Masonic Charities of Arizona is a non-profit organization whose objective is to channel contributions from Masons, the general public and others into an endowment fund whose earnings support children’s hospitals, scientific and medical research relative to catastrophic diseases, educational scholarships, and agencies organized to relieve human suffering caused by illness or poverty throughout the State of Arizona.

To carry out this objective, Masonic Charities seeks grant applications from Arizona non-profit health and welfare agencies.

Deadline – Completed applications should be postmarked no later than July 10, 2010, and are to be mailed to Paul Doré Sr., Secretary-Treasurer, Masonic Charities of Arizona, 345 W Monroe St, Phoenix, AZ 85003-1684.

Application Requirements –

Organization:___________________________________________________________

Mailing Address:___________________________________________________________

Telephone:___________________________________________________________

Contact Person:___________________________________________________________

Contact Telephone:_____________________________Fax:__________________________

Contact E-mail___________________________________________________________

Certification:I,                                               , am the duly appointed representative of                                             (Name)

                                                                        , authorized to certify and affirm all statements and

                     (Organization)                      

certifications in this application.                                            ____________________________

                                                                                                                       (Signature)        

(Typed or Printed Name)

                                                                                                                                                                                               (Title)

Date Completed_________________________

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Masonic Charities of Arizona – Grant Application                                                            Page 2

ATTACHMENTS

Attachment A – A copy of the organization’s most recent IRS determination letter that recognizes the organization as tax-exempt under 26 U.S. C. 501(c) (3) and to which contributions are tax deductible pursuant to 26 U.S. C. 170.

Attachment B – A copy of the organization’s most recently completed IRS Form 990. (NOTE: If the IRS does note require the organization to filed a Form 999, it still must be completed in accordance with IRS regulations to be eligible to receive a grant).

Attachment C – A statement describing the programs, services, benefits, etc., provided by the organization within the previous year, and how those programs, services and benefits affect the human health and welfare of the organization’s target population.

CERTIFICATIONS

□    I certify the organization named in this application is a human health and welfare organization providing services, benefits, or assistance to, or conducting activities affecting human health and welfare.

□    I certify the organization named in this application has spent 25% or less of its total support and revenue on administrative and fundraising expenses during the year covered by the submitted IRS Form 990. The actual percentage of administrative and fundraising expenses is ______%. This percentage has been computed from information on the Form 990 by adding the amount spent on “management and general” (line  14) to “fundraising” (line 15) and dividing the resulting total by “total revenue” (line 12).

□    I certify the organization has a governing board whose members have no material conflict of interest and a majority of which serve without compensation. Include as ATTACHMENT D a listing of the organization’s board of directors, beginning ending dates of each member’s term of office, and the board’s meeting dates and locations for the previous year.

□    I certify the organization is chartered/incorporated under the State of Arizona.

CONTACT INFORMATION

Paul Doré Sr., Secretary-Treasurer, may be contacted at the address stated above, by telephone (602) 920-0456 or (928) 425-2891, or by e-mail: pauldoresr@cox.net.