The Horace A. Kimball Foundation

General Information:

Name of Organization:
Contact Name:

Address:


City:
State:	Zip:

Email Address:
Phone:
Fax:

Statement of Intent:

(Please make this concise. Form only allows 5000 characters, including spaces.)

For Previous Grant Recipients:

If you have been awarded a gift by the The Horace A. Kimball & S. Ella Kimball Foundation previously, we would like you to share how you have used the funds.
If you have never been awarded a grant by the foundation, you may leave this field blank.

Verification of 501(c)(3) and 509(a) Status:
501(c)(3) Id #: Date of Issuance: or

509(a) Id #: Date of Issuance:

If this is the first time a request has been made to the Kimball Foundation, please indicate your intent to provide copies of 501(c)(3) and 509(a) verification documentation by mail to the Foundation.
(Send documentation to H. Kimball Foundation, 130 Woodville Road, Hope Valley, RI 02832)

Copies of verification documents will be sent to the Foundation:

Financial Information:
All figures should be rounded to the nearest dollar. The Kimball Foundation realizes that your financial information could have different headings and sub headings - please do your best to fit them into the following areas to make them as standard as possible.

Balance Sheet as of: (date)

Current Assets
Cash
Accounts Receivable
Inventories
Prepaid Expenses
Total Current Assets
Property and Equipment
Land
Building and Improvements
Furniture and equipment
Less accumulated depreciation
Net of Property & Equipment
Other Assets
Total Assets (should equal total Liabilities & Equity)

Current Liabilities
Accounts Payable
Accrued Liabilities
Short Term Debt
Total Current Liabilities
Long Term Debt
Other Liabilities
Equity
Total Liabilities and Equity (should equal Total Assets)

Additional Comments on the Balance Sheet:

Income Statement for period ended: (date)
Revenues & Support
Grants
Contributions
Donations
Earned Revenue
Interest Income
Miscellaneous Income
Total Income
Expenses
Salary of Highest Paid Full Time Employee*
Salary of 2nd Highest Paid Full Time Employee* *(These salaries are those of employees of the organization that will benefit from the gift, if awarded)

Wages and other salaries
Payroll taxes and benefits
General Administration Expenses
Miscellaneous Expenses
Total Uses of Income
Number of full time employees:
Number of part time employees:
Total number of paid employees:
Number of volunteers:

Please use the following space to list specific contributors (i.e., other foundations, etc.) and provide any additional comments regarding Revenues & Support:

When you submit this form, you will be redirected to a confirmation page, which indicates that the form has been properly sent. It may take a few moments for your submission to be processed; please be patient.
You will not receive an e-mail confirmation of your submittal.