Part One: Applicant Information - PG&E, Pacific Gas and ...



SAMPLE 2012 Online Grant Application

This is a sample grant application and will not be accepted for consideration for a grant request.

All grant applications must be submitted online.

Please visit our website about/community/contributions to find out more about PG&E’s Community Investment Program and how to apply for a grant.

Organization Information

Are you a Fiscal Sponsor? Yes or No

If YES, please answer all of the questions in this application as they relate to your organization, not the organization you are sponsoring for this grant.

Federal Tax ID

Organization Official Name - This should be your Official Legal Name as it is currently listed with the IRS.

Also Known As - If your organization has a different name than is listed above, enter it here. (Optional)

Organization Address -This address is where all correspondence will be mailed.

Address City State Zip Code

Organization Location (City/County) - Select from the list the best match to your organization's physical location.

Organization Main Phone Organization Main Fax Organization Website

Organization Executive Director - If you are a national nonprofit, please list your local chapter’s Executive Director.

Prefix First Name Last Name

PG&E Primary Staff Contact - You must select the name of your PG&E Contact from the list provided. If you don’t know your PG&E contact, please refer to our website for a list of regional contacts.

PG&E Staff – Additional - If you have discussed this proposal with any additional PG&E employees not listed above, please enter their names here (Optional)

Board of Directors - Please list the names of any PG&E employees who currently serve on your Board of Directors (Optional)

Contact Information

Organization Contact

Prefix First Name Last Name

Title in Organization Direct Phone Email

___Check this box if the Request Contact is the same as the Organization Contact listed above

Request Contact

Prefix First Name Last Name

Title in Organization Direct Phone Email

Proposal Information

Request

Request Date - This will be automatically filled by the system.

Request Amount $

Grant Description Title -This should be the descriptive title or name of your project. If you are a Fiscal Sponsor, please include the name of the non-exempt organization you are sponsoring in the title.

Project Description - This should be the detailed description of the project or program for which you are requesting funding.

Focus Area - Select from the list provided the choice that best describes the focus of your proposal.

In what county or area will this grant primarily be used? - Please select the county where the MAJORITY of the funds will be used. If you are requesting funding for a project that is regionally-based or will impact multiple counties, you may select up to three counties to represent the area covered. If your project is statewide or outside of California, please select the choice that best represents where the funds will be used.

How will PG&E be recognized for this donation throughout the upcoming year? - Please give specific examples such as: public recognition on website, newsletters, media advisories, event signage etc.

Funds Distribution

Please provide a dollar amount for each applicable category below.

Project or Program Amount $

General Operating Amount $

Capital Amount $

Event Amount $

Statistical Information

In order to benchmark and illustrate PG&E's commitment to community investments, we ask that you please answer the following questions specific to this grant request.

Please note this data is used for statistical purposes only and it does not affect the grant approval process.

Primary Target Population (Select One)

Disabled / Homeless / LGBT / Seniors / Veterans / Women & Girls (all ages)

Age Group Target Population (Select Up To Three)

(You may select up to three if your target population includes more than one age group of children.)

Infants (0-5) / Children (6-13) / Youth (14-18) / Adults (19-55) / Seniors (55+) / All (General Audience)

Gender of Target Population (Select One) Female (only) / Male (only) / All (General Audience)

Will at least half of the requested grant amount be used to benefit an Underserved Population?

Yes or No

Will at least half of the requested grant amount be used to benefit Low Income Households?

Yes or No

Please provide a dollar amount for each applicable category below as it relates to this grant request. (Please enter zero (0) where non-applicable. The total does not need to equal the full grant amount requested.)

African-American $

Asian-American (includes Pacific Islander) $

Latin-American (Hispanic) $

Native-American $

Do the majority of your Board of Directors identify as a member of a minority? Minority in this context is defined as someone who identifies as a member of any ethnic group other than Caucasian, and/or women, LGBT or disabled. Majority is defined as more than 50%. Yes or No

Compliance and Certification

Please read this section thoroughly and confirm that your organization is in compliance with the following terms and conditions. Please note that disagreeing to any statement will disqualify you for a charitable donation.

Compliance Disclosures

The applicant is, and shall remain, in compliance with all federal, state, and local laws, rules, and regulations, including if applicable the California Nonprofit Integrity Act of 2004.

The applicant does not and shall not, in its by-laws, policies, or practices, discriminate on the basis of race, color, religion, age, sex, national origin, ancestry, physical or mental disability, medical condition, veteran status, marital status, pregnancy, sexual orientation, gender identity, or any basis prohibited by applicable law.

The applicant agrees that any donation from PG&E will be used only for charitable purposes, and will not be used to promote or oppose any candidate or ballot measure, to advocate any legislative or administrative action, or to personally benefit or compensate any elected official.

The applicant and each of its grantees, if any, is in full compliance with all statutes, Executive Orders, and regulations restricting or prohibiting U.S. persons from engaging in transactions and dealings with countries, entities, or individuals subject to economic sanctions administered by the U.S. Department of the Treasury's Office of Foreign Assets Control, the applicant is aware that a list of countries subject to such sanctions, a list of Specially Designated Nationals and Blocked Persons subject to such sanctions, and overviews and guidelines for each such sanctions program can be found at , and the applicant does not and shall not promote or engage in violence, terrorism, bigotry, or the destruction of any state, or make grants or otherwise furnish support of any kind to any individual or entity that engages in such activities. Should any change in circumstances pertaining to this certification occur at any time, the applicant will notify the Community Relations Department of Pacific Gas and Electric Company immediately.

I certify that the above four statements are true to the best of my knowledge.

Agree___ Disagree ___

Certification

I am the duly appointed representative of my organization. I'm authorized to certify and affirm all the statements above, and to submit the application on behalf of my organization.

I have read all the statements and responses in this application, and certify that each is accurate.

I agree that electronic submission of this application will be deemed to be the equivalent of my written signature for purposes of this certification and application.

By accepting any funds or in-kind donations from PG&E, my organization agrees to all terms, conditions and certifications specified within the application and the transmittal letter.

My name is:

My position title with this organization is:

Signed by (enter name) Signed on this date

Attachment Instructions

NEW for 2012 we require a current W-9 be attached to your application.

The W-9 form must be SIGNED and DATED to be accepted.

Make sure your W-9 is:

1. Signed by an official of the organization.

2. Dated no more than 5 months from the submission date of this application.

3. A match to what is on file with the IRS.

NEED A FORM? Download the newest W-9 form from the IRS by clicking here.

Please follow these 4 steps to complete your W-9 form:

1. Download a copy of the form.

2. Fill out the entire form

3. Print your completed form and sign and date it.

4. Scan the signed completed form and attach the file to your application.

*If you do not have a scanner, please fax your completed form to your PG&E contact who will then scan it and email it back to you for attaching to your application.

If you have recently changed your physical or mailing address and have not updated it with the IRS, do not enter it on the W-9, but update it on the Organization Information section at the beginning of this application.

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HELFPUL HINT – This application is divided into four sections; Organization, Contact, Proposal, and Compliance and Certification. We suggest reviewing all sections with your PG&E staff contact prior to starting an online application. If you do not have a PG&E contact, please refer to the Regional Contact list on our website.

HELPFUL HINT – This section includes two contacts. The ORGANIZATION Contact is the primary day-to-day contact for your organization. The REQUEST Contact is the person that is making this grant request on behalf of your organization. This may be the same or different depending on your organization’s structure.

HELPFUL HINT- Enter the dollar amount you will be using for each category. The total of all should equal your Request Amount entered at the top of this application. Enter zero (0) where non-applicable.

Example: Request Amount = $1,000: Project $500, General Operating $0, Capital $0, Event $500

HELPFUL HINT – Your W-9 form needs to be signed and dated less than 5 months from the time you submit your application in order to be accepted. We recommend downloading a form directly from the IRS and having it completed, signed and dated prior to starting your application so you can be sure it up to date.

HELPFUL HINT –Submitted applications CANNOT be changed, so we recommend that before you hit SUBMIT you click SAVE & FINISH LATER and email a copy to your PG&E staff contact for their final review. The email option is available directly from your account under Action on the far right of the screen.

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