PG&E Grant Application

Transcription

1 Please enter your official IRS issued Tax ID number. If you are a Fiscal Sponsor applying on behalf of a non-exempt organization, enter your Tax ID number Grant Period PG&E Grant Application Organization Information 1. Tax ID: This is the official Tax ID number of the exempt organization that will receive funding. *NOTE: Fiscal Sponsors this should be your Tax ID since you are the tax-exempt organization 2. Are you a Fiscal Sponsor for this grant request? (Yes, No) If Yes, provide name of organization receiving the funds: Please answer all of the questions in this application as they relate to your organization, not the organization you are sponsoring for this grant. If you need more information about fiscal sponsorship or are unsure on how to complete this application, please review the information from our website, by clicking on the FAQs link at the top right of this page. 3. Organization Official Name: This should be your Official Legal Name as it is currently listed with the IRS. If you have recently changed your name and not updated it with the IRS, please change it in the next field called Also Known As 4. Also Known As: If your organization has a different name than is listed above, enter it here. (Optional) 5. Organization Address: This address is where all correspondence will be mailed. This is the organization address where we will mail all documents. If you are a local branch office of a national organization, enter your address and not that of the national office. If you have recently moved and have not updated your address with the IRS, please enter the new information here. *NOTE: Fiscal Sponsors this should be your address and not that of the organization you are sponsoring for this grant. City: State: Zip Code: Organization Location (City/County): This is a list of areas by both county and city. If your exact county/city combination isn't listed, then select just the county. If you are a local branch office of a national organization, enter your address and not that of the national office 6. Organization Main Phone: Please enter phone number with area code as: ###-###-#### 7. Organization Main Fax: 8. Organization Website: Include the full URL for your organization's website. (Example:

2 9. Does your organization use social media? (Yes/No) (i.e., Facebook, Twitter, Yammer, etc.) 2013 Grant Period If Yes, please describe in this section: An example is provided in this information icon. Many of your fellow community members and leaders may be active on Facebook and Twitter, and you may have already established a strong network through your organization s Facebook page and Twitter handles. If that is the case, these platforms may serve as useful tools for promoting your participation in the PG&E Community Investment Program. If applicable, please provide the social media handles your organization uses. Also, describe any social media recognition opportunities associated with the grant you are requesting from PG&E. Please note: this is not a requirement for participation in PG&E s Community Investment Program. 10. Organization Executive Director: Please list your Local Branch Executive Director if you are a branch office of a national organization. *NOTE: This may be different than the information you will provide in the next section of this application for Organization Primary and Request contacts. Prefix: First Name: Last: 11. PG&E Primary Staff Contact: You MUST select one name from this list to submit your application. If your PG&E Contact is not listed, or you have not discussed this proposal with anyone, find the correct regional contact by clicking on the HELP link at the top of the page. *NOTE: You will need to forward the confirmation you receive, once you have submitted your application, to this primary PG&E contact. You may write in any additional PG&E contacts in the next question below. 12. PG&E Staff Additional: (short text) If you have discussed this proposal with any additional PG&E employees not selected above, please enter their names here. This is in addition to the PG&E contact you selected in the previous question. *NOTE: You will need to forward the submission confirmation you will receive once you have submitted your application to your primary PG&E contact. 13. Board of Directors: Please list the names of any PG&E employees. This field is optional and has no influence on your proposal. Please list names as follows: First Name 1, Last Name 1; First Name 2, Last Name 2; etc. Contact Information This section contains two parts. First is the primary day-to-day contact for your organization and the second is the contact for the grant request. If they are the same, after completing the first section, simply check the box next to Same as Organization Primary Contact and the form will automatically update. 14. Organization Contact: Prefix: First Name: Last Name:

3 Title in Organization: Direct Phone: Please enter phone number with area code as: ###-###-#### Grant Period 15. Request Contact: Same as Organization Primary Contact Check this box if the Request Contact is the same as the organization contact listed above. Prefix: First Name: Last Name: Title in Organization: Direct Phone: Please enter phone number with area code as: ###-###-#### Proposal Information 16. Desired Funding Date: 17. Grant Request Amount: 18. Grant Title: Please give a brief descriptive name or title to your grant request. *NOTE: Fiscal Sponsors please list the name of the non-exempt organization you will be sponsoring in this title. 19. Grant Description: Describe the project or program which will be funded by this grant request. *NOTE: Fiscal Sponsors please include the name of the non-exempt organization you are sponsoring in the description. 20. Focus Area: <Select One> EDUCATION-Leadership Development: job skills, leadership. EDUCATION-Aid to Schools ENVIRONMENTAL STEWARDSHIP-Energy Efficiency ENVIRONMENTAL STEWARDSHIP-Sustainable Communities: environmental protection, conservation, restoration, green building, recycling ENVIRONMENTAL STEWARDSHIP-Climate Change and Renewable Energy ENVIRONMENTAL STEWARDSHIP-Parks and Recreation ENVIRONMENTAL STEWARDSHIP-Air: clean air COMMUNITY VITALITY-Emergency Preparedness: disaster relief, emergency training, program, safety training COMMUNITY VITALITY-Economic Development: business incubators, job creation, economic analysis and growth, vocational training COMMUNITY VITALITY-Health & Human Services: hospitals, united way, youth intervention, substance abuse, food programs COMMUNITY VITALITY-Arts & Culture: museums, operas, theaters, symphonies, dance/performance Select from the following list the focus area that best matches your project or program. 21. In what county or area will this grant primarily be used? <Select One> Area 1 - San Francisco Area 1 - San Mateo Area 2 - Alameda Area 2 - Contra Costa Area 3 - Monterey Area 3 - San Benito Area 3 - Santa Clara Area 3 - Santa Cruz Area 4 - Los Padres Area 4 - San Bernardino Area 4 - San Luis Obispo Area 4 - Santa Barbara Area 5

4 - Alpine Area 5 - Amador Area 5 - Calaveras Area 5 - Mariposa Area 5 - Merced Area 5 - San Joaquin Area 5 - Stanislaus Area 5 - Tuolumne Area 6 - Butte Area 6 - Colusa Area 6 - El Dorado Area 6 - Glenn Area 6 - Lassen Area 6 - Modoc Area 6 - Nevada Area 6 - Placer Area 6 - Plumas Area 6 - Sacramento Area 6 - Shasta Area 6 - Sierra Area 6 - Siskiyou Area 6 - Sutter Area 6 - Tehama Area 6 - Trinity Area 6 - Yolo Area 6 - Yuba Area 7 - Humboldt Area 7 - Lake Area 7 - Marin Area 7 - Mendocino Area 7 - Napa Area 7 - Solano Area 7 - Sonoma Area 8 - Fresno Area 8 - Kern Area 8 - Kings Area 8 - Madera Area 8 - Tulare California (statewide) National Organization Outside of California Southern California Texas/Southwest Washington, DC 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. If you are unsure how to answer this question, please contact your PG&E Staff contact for more information. 22. 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. 23. Funds Distribution: Please provide a dollar amount for each applicable category below. The total of all should equal your Request Amount. Enter zero (0) where non-applicable. 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. 24. Primary Target Population <Select One> Disabled - Homeless - Lesbian/Gay/Bi-Sexual/Transgender (LGBT) - Seniors (greater than 55 years of age) - Veterans Women & Girls (all ages) - All (general audience) 25. Age Group: <Select One> 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) If the target population includes more than one age group of CHILDREN you may select up to three choices, but if the target population is all ages, (e.g. seniors, youths and adults), than simply select ALL as your choice. 26. Gender of Target Population: <Select One> Female Only - Male Only - All (general audience) 27. Will at least half of the requested grant amount be used to benefit an Underserved Population? (Yes/No) Underserved Population is defined as any of the following; Any Specific Ethnic Group; Disabled; Homeless; Lesbian, Gay, Bisexual, Transgender (LGBT); Seniors; Veterans; Women & Girls. 28. Will at least half of the requested grant amount be used to benefit Low Income Households? (Yes/No)

5 Low Income Households is defined consistent with the Uniform Relocation Assistance and Real Property Acquisition Policies Act of Fiscal Year 2012 limits may be found at Please provide a dollar amount for each applicable ethnic group 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): Latino-American (Hispanic): Native-American 30. Do the majority of your Board of Directors identify as a member of a minority? (Yes/No) 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%. 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. 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 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.

6 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: (initial) Signed on this date: Attachments A fully completed IRS W-9 form must be attached to your application. Please follow these 3 steps to complete your W-9 form: 1. Download a W-9 form by clicking here (Grant page/ Requirements) 2. Fill out the entire form. 3. Scan the signed completed form and save the file in your computer Documents. Note: If you do not have a scanner, you may reach out to your PG&E contact for assistance. Upload the file to your grant application. Make sure your W-9 is: 1. Signed by an official of the organization. 2. The form must be SIGNED and DATED no more than 2 months from the submission date of this application to be accepted. 3. A match to what is on file with the IRS. 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. Error occurred while uploading attachment: Please insure the file path is valid. Upload Review & Submit

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