The Horace A. Kimball Foundation

General Information:

Name of Organization:
Contact Name:

Address:


City:
State:	Zip:

Email Address:
Phone:
Fax:

Statement of Intent:

(Please make this concise. Form only allows 5000 characters, including spaces.)

Verification of 501(c)(3) and 509(a) Status:
501(c)(3) Id #: Date of Issuance: or

509(a) Id #: Date of Issuance:

If this is the first time a request has been made to the Kimball Foundation, please indicate your intent to provide copies of 501(c)(3) and 509(a) verification documentation by mail to the Foundation.
(Send documentation to H. Kimball Foundation, 130 Woodville Road, Hope Valley, RI 02832)

Copies of verification documents will be sent to the Foundation:

Financial Information:
All figures should be rounded to the nearest dollar. The Kimball Foundation realizes that your financial information could have different headings and sub headings - please do your best to fit them into the following areas to make them as standard as possible.

Balance Sheet as of: (date)

Current Assets
Cash
Accounts Receivable
Inventories
Prepaid Expenses
Total Current Assets
Property and Equipment
Land
Building and Improvements
Furniture and equipment
Less accumulated depreciation
Net of Property & Equipment
Other Assets
Total Assets (should equal total Liabilities & Equity)

Current Liabilities
Accounts Payable
Accrued Liabilities
Short Term Debt
Total Current Liabilities
Long Term Debt
Other Liabilities
Equity
Total Liabilities and Equity (should equal Total Assets)

Additional Comments on the Balance Sheet:

Income Statement for period ended: (date)
Revenues & Support
Grants
Contributions
Donations
Earned Revenue
Interest Income
Miscellaneous Income
Total Income
Expenses
Salary of Highest Paid Full Time Employee
Salary of 2nd Highest Paid Full Time Employee

Wages and other salaries
Payroll taxes and benefits
General Administration Expenses
Miscellaneous Expenses
Total Uses of Income
Number of full time employees:
Number of part time employees:
Total number of paid employees:
Number of volunteers:

Please use the following space to list specific contributors (i.e., other foundations, etc.) and provide any additional comments regarding Revenues & Support:

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You will not receive an e-mail confirmation of your submittal.