Legal Aid of Manasota
Un-Incorporated Non-Profit Application

Community Counsel Program

Please fill out the form below to apply.

Organization Information
(Proposed) Name of Organization
Address
City/State/Zip
,
Phone
Fax
E-Mail

Organization Contacts
Primary Contact
Primary Contact Phone
Primary Contact Address
Primary Contact Position/Office
Primary Contact E-Mail
Secondary Contact
Secondary Contact Phone
Secondary Contact Address
Secondary Contact Position/Office
Secondary Contact E-Mail

Purpose of Organization

Geographic Target Area
Geographical Area
County

Will this Organization primarily serve low-income people?
Yes, this Organization primarily serves low-income.
No, this Organization does not primarily serve low-income.

If so, approx. how many people will it serve annually?

Is the Organization financially able to retain and pay for a private attorney?
Yes, this Organization is able.
No, this Organization is not able.

Has the Organization retained and paid an attorney in the past 12 months?
Yes, this Organization has retained an attorney.
No, this Organization has not retained an attorney.

If yes, please enter list.

General Statement of Problem

(check all that apply)
Incorporate Organization
Obtain Tax-Exempt Status
Other (describe below)

What was the Gross receipts of the Organization last fiscal year?

How did you learn about the Community Counsel project?

I hereby certify that the above information is correct.
Signature

Office/Title

Date (MM-DD-YYYY)