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Program Guide

NH Nonprofit Response Fund Application

First Submission Date is 4/13

Note: Before completing this application, please be sure to review our Application and Program Guide.

Today's Date
Date Format: MM slash DD slash YYYY
Primary Contact Information
Name*
First Middle Last
Title*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Alternate Phone (Cell)
Email*
Organization Information
Organization Name*
Type*
Tax ID*
Website*
Fiscal Year End*
Date Format: MM slash DD slash YYYY
Business Address*
Street Address Address Line 2 City State ZIP Code
Business Phone*
Authorized Official Name*
First Last
Authorized Official Email*
Funding Request
Up to $100,000 maximum total combined request
1. Forgivable Loan Amount Requested
2. Loan Amount Requested
TOTAL Amount Requested
3. What will your organization use these funds for?*
If "Other", please describe how you will use the funds
4. How specifically would you use the funds you are requesting to stabilize your nonprofit or provide services to individuals harmed by COVID-19 and over what time period?*
5. Are you in a position to deploy these funds immediately, and if not, what is your timeline?*
6. Is your nonprofit still operating?*
- Yes
- No
7. Have you had to curtail services, alter your services, or are you considering closing your nonprofit because of the COVID-19 restrictions? Y/N?*
7a. If Yes to Question 7, please describe.
8. If your nonprofit experienced a drop in revenue due to COVID-19, what is the percent drop by week?
9. Have you laid off any employees?*
9a. If Yes to Question 9, please describe how many and what functions did they provide?
10. Are you considering laying off additional workers?*
11. What is your most critical concern right now?*
12. What other sources have you pursued and what is the status of other funding?*
Management Capacity
1. Management Team – Please describe who will be responsible for oversight, reporting and other activities related to this funding.*
Financial Capacity & Collateral
Please attach the following items to your application:
1. List of or link to Board of Directors (including affiliation)*
Drop files here or
2. Management Prepared Financial Statements for last complete Fiscal Year (Balance Sheet, Profit and Loss, Cash Flow)*
Drop files here or
3. Financial Statements for most recently completed Fiscal Year (provide ONE of the following, listed in order of priority)*
Audited Financial Statement (required for organizations with operating budgets > $1 M); Review Financial Statement (required for organizations with operating budgets $500,000 - $1M); IRS Form 990 (required if no Audited or Review Financial Statement available).
Drop files here or
4. Fiscal year end date*
Date Format: MM slash DD slash YYYY
4a. Management Prepared Financial Statements for current Fiscal Year to date (Balance Sheet, Profit and Loss, Cash Flow) if your Fiscal Year end falls between March 31 and September 30.
Drop files here or
5. Budget-to-actual for most recent completed fiscal year (for requests greater than $50,000)
Drop files here or
6. Current fiscal year operating budget*
Drop files here or
7. Outstanding Debt. Please download, complete, and then upload this Debt Schedule.
File Upload*
Drop files here or
8. Please describe any potential collateral that may be available to secure the loan.*
Certification
Full Name of Certifying Officer*
First Middle Last
Please download, sign and then upload our Application Certification Form.
Authorized Official Certification Form*

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Application

Resources

Application

NH Nonprofit Response Fund Application

First Submission Date is 4/13

Primary Contact Information

Organization Information

Funding Request

Management Capacity

Financial Capacity & Collateral

Certification

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