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2. Name of Non-Profit Organization*
4. Address1*
   Must be the local branch address
6. Address2*
8. City*
9. State*
10. Zip*
12. Grant Applicant Representative's Name*
    Must be the Executive Director or their designated representative.
13. Representative's Telephone Number*
15. Representative's E-mail Address*
17. Description of Community Services Provided*
19. List Areas Served by Non-Profit Organization*
    Include a brief description of the relationship of your non-profit organization to the residents of the City of Westlake Village (Los Angeles County)
21. Number of City of Westlake Village Residents Served by Non-Profit Organization*
    Los Angeles County only and broken down into age groups if possible.
23. Amount of Funds Requested*
24. Number of Staff, Volunteers, and Members*
    Please separate S= V= M=
26. Proposed Use and Budget Plan for Grant Funds*
    Please indicate if any of the grant funds would be used for any other purpose than those designated such as overhead, national office, or administrative salaries.
28. Previous Funds Received*
    Please indicate if you have received funds in the past, the amount of funds received, the year they were awarded, and how the funds were utilized.
30. Uploading Material Information
    Please note that each box will only upload one document. Please scan and submit all materials as one PDF for each category and then upload them. If you upload more than one item, only the final item will be sent with your application.
32. Financial Statements Last Year*
    Please upload the past year's financial statements including the current year with the balance sheets and profit/loss statements in a PDF format. Must also include a document indicating the percentage of revenue received that is used for administration, salaries, and program costs alongside a breakdown and description of non-profit organization's sources of revenue.
33. Financial Statements 2 Years Ago*
    Copy of same sets of paperwork from two years ago.
35. Proof of Non-Profit Status*
    Please upload the proof of 501(c)(3) status with a copy of the letter from the IRS in a PDF format.
36. Non-Profit Board Information*
    Please upload the copy of the non-profit organizations Board of Directors, Officers, and an organizational chart in a PDF format.
37. Additional Uploads*
    If you have any marketing information, event flyers, or additional paperwork here. Please scan as all one PDF document.
39. Certification*
    -- Select One --I agreeI disagree

    I certify on behalf of the above named non-profit organization, that I have read, understand and agree that the aforesaid information is accurate, factual, and current. I understand that an award of funds, if granted, will be for the sole use as reflected in this application form. I further certify that as a condition of receiving funds, an agreement with the City of Westlake Village, in a form and content provided by the City of Westlake Village, will be signed and executed by a duly authorized representative of said non-profit.
41. Name of Exective Director or Designee*
    By typing in my name I am acknowledging the submission of this document.
42. Date of Submission*
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field