The Jean E. Thomson Foundation

1740 Karl Johan Avenue South

Tacoma, WA 98465-1224

Grant Request Information Form

*Qualifications To Apply

Organization located in Tacoma/Seattle, WA or Minneapolis, MN ? YES___ NO___

Organization Type= Religious, Charitable, Scientific, Literary, or Education ? YES___ NO___

If “No” is checked on either of the above, your Organization does not qualify.

*Applicant’s Organization Info

Organization Name_________________________________________

Applicant Name____________________ Position__________________

Address____________________ City__________ State___ Zip______

Phone________________ Fax_____________ Email________________

*Organization Status

Current Internal Revenue Status- 501(c)3 ? YES___ NO___ Other_________

If “Other” is checked, please explain_______________________________

___________________________________________________________

Federal Tax Identification Number______________________

Is a copy of your IRS Status Determination Letter Enclosed? YES____ NO____

If “No” is checked, please explain___________________________________

Is a copy of your Most Recent 990 IRS Return enclosed? YES____ NO______

If “No” is checked, please explain___________________________________

*Grant Request Information

Please describe your Organization’s Mission Goals_______________________

____________________________________________________________

Amount of Your Grant Request $______________________

Please describe the purposes for the Grant you are requesting_______________

_____________________________________________________________

______________________________________________________________

Date_________ Printed Name_______________ Signature_________________