Directions: Please print this form, complete all fields, sign it and mail to Women's Fund, 525 East Capitol Street, Suite 5B, Jackson, MS 39201.

The below signed accepts responsibility for submission of a grant application to the Women's Fund of the Community Foundation of Greater Jackson by _____________________________ (organization) for __________________________ (project, if applicable), attesting that all information submitted in the application materials is true and accurate to the best of his or her knowledge and that any funding, should it be awarded, will be expended only for the purposes outlined in the grant proposal. The applicant acknowledges that it has been disclosed that submission of an incomplete or inaccurate proposal constitutes grounds for denial and that if information contained in the proposal is deemed to be false or funds are expended for purposes other than those expressly stated in the application without prior written consent of the Women's Fund any grant monies must be repaid to the Women's Fund.

Name: ______________________________________________________________

Signature: ________________________________________ Date: _____________