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2. Instructions for Outside Agency Funding Request
   The instructions detailed are for any outside agency that is requesting funding assistance from Goochland County. These instructions must be complied with in order for the funding request to be considered by the Goochland County Board of Supervisors in the upcoming fiscal year budget. Upon completing the Application for Funds, you will be required to sign a statement certifying to the accuracy of the information submitted and agreeing to allow Goochland County Officials to review your books and records upon request, if they should so request. Goochland County shall publish its intent to provide funding to your organizations in the local newspaper. The records that your organization submits to Goochland County regarding your finding request will be open for public inspection.
4. Application for Funds
6. Name of Organization
8. Address1
10. Address2
12. City
13. State
14. Zip
16. Phone
18. Type of Organization

    1. Charitable
    2. Civic
    3. Governmental
19. Tax Identification Number
21. Purpose of Organization
23. Contact Person
25. Email Address
27. Title
28. Phone Number
30. Amount of Appropriations Request for current FY.
31. Amount received from Goochland County in prior FY.
33. Please briefly explain how funds will be used.
35. How many Goochland Residents are served by your organization?
37. List your other Revenue sources
39. What would be the impact on your organization if Goochland did not contribute or only partial fund your request?
41. Other Comments
43. Certifying Statement
    I hereby certify that to the best of my knowledge and belief that the information with this request is accurate. The Organization also agrees to allow Goochland County to review the books and records of this agency should they so desire.
45. Submit Form
    By submitting this form I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature.
47. Date
    Date
49. Name
50. Title
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit Submit and Print

* indicates a required field