Mini-Grant Checklist

	Granted funds will be used for items/services that are associated with and will ultimately impact mental health.	

	This agency is a 501(c)3 agency as described in IRS tax code.	

	This agency has enclosed a copy of its federal tax exempt status letter.	

	Granted funds will be used within McHenry County, Illinois.	

	This application requests items/services that can be purchased immediately.	

	Items/services can be purchased within 15 days of receiving this grant.	

	This agency agrees (through its authorized officers or directors) to cooperate fully in accounting for the use of all funds received from the MHRL.	

	This agency agrees to represent MHRL in a positive manner in all correspondence regarding this grant (newsletters, website, etc.).	

	This agency acknowledges that no re-direction of funds is allowed and that granted funds MUST be used for applied purposes.	

	This agency has NOT received an Immediate Grant from MHRL within the past year.

Please Note: It is not necessary to hand in this checklist with your application. This checklist is for your internal use only. Please use the checklist to verify that your agency meets the criteria of the Immediate Grants Fund as specified by the MHRL. By filling out and submitting a grant application for the Immediate Grants Fund you attest to the fact that you meet the criteria outlined in the checklist above.

Mini-Grant Application

Organization:

Mailing Address (and Physical Address if it is different and not confidential):

Telephone:  				   			Federal EIN:

Website:							          

General Email Address:

Name of CEO or Executive Director: 

Telephone:				 CEO Email:
Application Contact & Title (if not the CEO or Executive Director):

Telephone:				    Email:

Organization Information	
Year Founded:
Which communities are served by your agency:

Tax Exempt Status:			     501(c)(3)

IRS Determination Letter Attached:	

Grant Application Information	

$

Amount of Request ($500 or less):    

Please describe what the grant will be used for. Your grant request:

•	is limited to 100 words or less;
•	must be concise;
•	must be clear; and
•	must demonstrate obvious need.

Note: Your agency’s CEO or ED must sign and date this form. Then, SCAN the completed form and your agency’s IRS determination letter and email to info@mhrl.org for consideration. Mailed applications are not accepted.

By signing below, I certify that the information contained in this application is true and correct to the best of my knowledge.

													
CEO/Executive Director 							Date