CHARITABLE FUNDING REQUEST FORM
Please print the following form and mail your request to:
LIONS CLUB OF SAN DIEGO
310 MARKET ST.
SAN DIEGO, CA 92101
or fax your packet to (619) 239-3539.
Funding, if approved at all levels, generally takes from four to eight weeks.
PLEASE REMEMBER TO INCLUDE YOUR PHONE NUMBER
and/or EMAIL address in your request.

NAME OF ORGANIZATION/INDIVIDUAL:

____________________________________________________________

DATE: _______________

I. SPECIFICS OF REQUEST:

A. What is being requested?

____________________________________________________________

B. Purpose of request:

____________________________________________________________

C. Identify other organizations, if any, contributing to this request.

____________________________________________________________

D. Have any other Lions Clubs been approached to assist with funding?

____________________________________________________________

E. If equipment, how it will be utilized and why is it needed?

____________________________________________________________

F. How many people will be served by this request?

____________________________________________________________

G. Will this be an annual request?

____________________________________________________________

H. Past funding history:

____________________________________________________________

I. If approved, check should be made payable to:

____________________________________________________________

Mailing address:

____________________________________________________________

II. IF ORGANIZATION:

A. Is it a tax exempt, qualified non-profit organization? _____________

B. Tax ID# ____________________________

B. When was it established? _________________--______

C. Does it have a Board of Directors? __________________

D. What are its sources of funding? United Way? ____________

Others? _____________________

E. What is its annual budget?

1. Total income: _______________________________

2. Total expense: _______________________________

F. Any reserves or endowments? [If yes, describe briefly:]

____________________________________________________________

G. Total paid employees, Full time: _____ Part time: _____

H. Are any of the funds requested going to staff or operating costs?

No______

Yes______[describe]__________________________________________

III. IF FOR AN INDIVIDUAL:

A. Where does person live?

____________________________________________________________

B. Is person U.S. citizen? ______
If no, what is residency status?________________

C. How old is individual? _____________________

D. What is gross monthly income of individual's household? ______________

E. What, if any, is specific disability?

____________________________________________________________ ____________________________________________________________

F. Provide medical summary/review, if applicable.

G. Is person working directly through any other charitable groups to obtain this request?

____________________________________________________________

H. If yes, can equipment {if applicable} be donated via this group for loan to individual? _________

I. What is anticipated impact to this individual [and others] if funding is approved?

____________________________________________________________

____________________________________________________________

{revised 10/1/98}