Application for Community Grant
Return completed form to the Wal-Mart Store or Sam’s Club where you obtained this application
Location Use Only
Location #: ___________
Type: WM / Sam’s / DC / TO _______________________
Managers Name (signed and printed): _____________________________________________________________________ Date: ___/___/________
Community Involvement Associate:
_____________________________________________________________________ Date: ___/___/________
This application must be completed and kept on file for record retention of three years at your location
To be completed by the Organization:
501 (c) (3)* organization
Federal, State or Local Government Agency
*Organizations with current tax-exempt status under Section 501(c) (3) of the Internal Revenue Service Code and that are also public charities under Section 509(a)(1) or
509(a)(2). *Organizations must be listed in the most current IRS 50 State Master File at the time of application.
Organization Name: __________________________________________________________________________________________________________
Federal 501 (c) (3) Tax ID #:
___________________________ Public Charity Status:
(9 digits) _
Address: __________________________________________________ City: ______________________________ ST: _____ Zip: _______________
Contact Name: _____________________________________________ Contact Phone: _______-_______-____________
Specifically, how will funds from this grant be utilized in your local community?
What service does your organization provide to the community?
Will these grant funds directly benefit your LOCAL community?
Which of the following groups will this funding primarily benefit? This information is used solely to track our funding to specific diverse community groups and is NOT considered during the
grant review or approval process.
Please select only the most appropriate:
General Population (benefits the entire community)
By signing below I acknowledge that this form represents a request for funding, and is not a guarantee of funding. Final approval is subject to the guidelines
of the Wal-Mart Foundation. All organizations requesting grant funding must abide by the rules and guidelines set forth by the location, Wal-Mart Stores, Inc., and the Wal-Mart Foundation. This
request will not be processed unless completed and signed by all parties.
Signed: ______________________________________________ Printed: ___________________________________________ Date: ___/___/______