Attorney General's Office

Massachusetts AGO Environmental Justice Fund Project Proposal & Funding Request Form

Name of Applicant/Organization (Include Address, City/Town) and contact information for purposes of this Request Form

Please provide a general description of your organization’s mission and purpose

If this organization is fiscally sponsored, name and address of sponsoring organization:

How much money is being requested?

What is the expected timeframe to complete the project?

Project Name and Location (Include Address, City/Town)

Please check one of more of the boxes below, that describes how your project fits into one of the legally authorized uses of the Environmental Justice Fund.

The restoration of any natural resource or the investigation, remediation or mitigation of any environmental pollution or harm on or at any real property located in a disadvantaged community

A project to benefit the community health or well-being, whether to address economic, environmental, or other health needs, of a disadvantaged community

To contribute to an academic or government-funded research project related to environmental protection or conservation of natural resources in a disadvantaged community.

Please describe your proposed project. Describe how it furthers the Environmental Justice Fund authorized use selected above. Describe any relevant project phases or tasks and indicate whether you have received or are seeking any other funding for the project.

Please provide a proposed budget using the sections below

Personnel

Task/Phase I

Task/Phase II

Task/Phase III

Total Cost

Supplies/Materials

Task/Phase I

Task/Phase II

Task/Phase III

Total Cost

Contractual Costs

Task/Phase I

Task/Phase II

Task/Phase III

Total Cost

Other

Task/Phase I

Task/Phase II

Task/Phase III

Total Cost

Total

Task/Phase I

Task/Phase II

Task/Phase III

Total Cost

If you are selected for funding, you must be in compliance with Massachusetts Public Charities requirements which may include submission of your annual tax filings for up to three years. The full filing includes a signed Form PC, IRS 990 Form, and a financial statement. Additional details and forms can be found at our Online Charities Filing Portal here:

https://www.mass.gov/info-details/online-charity-filing-portal.

Select one below

Your organization has submitted your annual filings and is already in compliance with the Massachusetts Public Charities requirements?

Your organization will work on coming into compliance prior to being awarded funding.

Your organization has not submitted your annual filings and is not willing or interested in submitting tax filing forms.

If you are selected for funding, you must sign a commitment letter confirming that you understand the statutory language of the Environmental Justice Fund, your project aligns with the legally authorized uses of the Environmental Justice Fund, your organization or fiscal sponsor is in compliance with the Massachusetts Office of the Attorney General’s Non-Profit/Public Charities filing requirements, you will use the money only for the purposes specified in the commitment letter, and your organization will submit, at least bi-annually, to the Massachusetts Office of the Attorney General a letter describing how the funds were spent.

Please provide contact information regarding your project

Name:

First Last

Mailing Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email:

Phone Number: