Community Partners Program Application Form

Please complete the following application in the space provided.

Organization Information

Name of Organization:
Federal Tax Identification Number:
Zip Code:
Organization Web Address:
Primary Contact:
Please list any Liberty Bank associates involved in your organization and their roles:
Please provide a brief overview of your organization and its mission:
Of the clients you serve, what percent are from low-to-moderate income areas?       %

Request Information

Amount Requested: $
Date of Application:
Type of Request (check one):  Operating
Briefly describe the nature of the request:
Does the request address at least one of Liberty Bank's funding priority areas?        Yes  No
If yes, check areas that apply:  Operating
Has the organization received a contribution from Liberty Bank in the last two years?        Yes  No
If so, please list
  Amount $
  Amount $
What are the timelines for the project and for fundraising?
What is the budget for the program/project (attach additional information as needed)?
Please outline other projected sources of funding for this project:
Please explain how you have measured or will measure the success of the program/project:


The undersigned certifies that they are authorized to represent the organization applying for a contribution and that the information contained in this application is accurate. The undersigned agrees that if a contribution is awarded to the organization: (1) the contribution will be used for the purpose outlined in the award letter and may not be expended for any other purpose without prior written approval from Liberty Bank; and (2) Liberty Bank has received nothing of material value, aside from noted sponsorship benefits, in exchange for the contribution.

 Signature of Applicant  Date

For more information contact:

Wil Hanger
Marketing and Event Specialist

Applications are welcomed at any time and are reviewed on a monthly basis by a committee of Liberty Bank associates. Applications will be acknowledged, and if necessary, a meeting will be arranged to discuss your request in further detail. All applications are given careful consideration. To ensure awards are made within the application's deadline, a minimum of 8 weeks is needed to process each application.

Following the review, each applicant will receive notification of the status of the request. We ask that you submit only one application within each calendar year. A donation or sponsorship request in one year does not make an organization automatically eligible the following year.