Placer County Revenue Sharing Fund Application

Organization Information

Organization Name

Address

Address line 2

City

State Value is not selected

Zip

Website Address

Is mailing address the same as physical address?

Yes

No

Mailing Address

Mailing Address 2

Mailing City

Mailing State Value is not selected

Mailing Zip

Describe the organization's purpose and/or mission and the people served

Briefly describe the program and/or event for which you are requesting funds

Are Revenue Sharing contributions being requested for a specific event?

Yes

No

Name of the event

Date of the event

Briefly describe how the event/program will benefit the County

Briefly describe how Revenue Sharing funding would be utilized. (Please list items and activities to be funded with any allotted Revenue Sharing funds. Funding cannot be used for core budget needs or for staffing related to programs or events, such as security, instructors, cleanup crews, etc.)

Contact Information

Contact Name

Phone Number

Email Address

Documentation

Please upload your most recent W9 form

Please upload your current year 590 form

Upload additional documents (optional)

I swear under penalty of perjury that the information supplied herein is true and correct *

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

I agree *

Electonic Signature Agreement

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Revenue Sharing Application

Placer County Revenue Sharing Fund Application

Organization Information

Contact Information

Documentation