Choose Life Alabama Fund

If you have multiple centers, you can only apply once.

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URL

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Name of Agency or Center*

Employment Identification Number (EIN)*

Official Location of Facility*

Street Address Address Line 2 City State ZIP Code

Mailing Address (If Different From Street Address)

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

501(c)(3) Status Documents*

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Officer or Director's Name*

First Last

Title*

Office Phone*

Director Cell Phone*

Email*

County In Which Your Agency Is Incorporated*

Address of Main Office*

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

Criteria for "Official Location": Owned, rented, or leased non-residential space for the purpose of providing regular daily or weekly services to women in need. Location shall have a permanent address, phone number, signage, regular operating hours, staff and general operating expenses such as utilities, building maintenance, etc. (Homes in residential areas or borrowed space for occasional use are not considered official locations for the purposes of applying for agency funding from APLCEF for FULL GRANT.) EXCEPTION: Maternity homes containing an office within the same structure may apply for a full portion of funds. Social Workers on contract with Adoption Agencies working out of their home will be eligible for 10% of the amount determined for each agency in their county Any other type of agency that does not have an official office with with signage will be given consideration and will need special approval from APLCEF before any funds will be distributed. To insure eligibility, be prepared for random site checks, requests for pictures of your facility, and requests for proof of rent or mortgage payments with facility address or proof of building ownership, if requested.

About Your Organization

Applying Agency is Primarily*

Crisis Pregnancy Center / Women's Resource Center

Maternity Home

Adoption Agency

Briefly State The Mission Of The Organization*

How Many Clients Did Your Agency Service Last Fiscal Year, July 1 - June 30?*

Does This Agency Involve Itself In Any Way With Abortion Activities, Does Anyone Representing This Agency Refer For Abortion Procedures, Or Does Anyone Representing This Agency Refer For "Morning After Pill"?*

Does This Agency Agree To Designate At Least 70 Percent Of Received Funds For Direct Assistance To Women Facing Unpanned Pregnancy?*

Is This Center Affiliated With Any National Organization That Oversees And Assists Pregnancy REsource Centers Such As Carenet, Heartbeat International, or NIFLA?*

If The Answer Is "No," Please Explain Why.

Has The Agency Board of Directors Examined The Following Qualifications, And Approve Of The Agency Applying For Funds Raised Within The County?*

We affirm and understand the following to be true:

That that qualified Agencies or Centers are defined as non-governmental, not-for-profit, tax-exempt 501 ( c ) ( 3 ) Agencies or Centers within this county? Do you understand that the Agencies’ or Centers’ services must include counseling and meeting the needs of women in an unplanned pregnancy who are committed to parenting their children, or placing their children for adoption.
That funds may not be distributed under any circumstances to any Agency or Center that is involved or associated with abortion advocacy or activities, including, but not limited to, counseling for, or referrals to, abortion clinics, medical abortions, or abortion advocacy or advertising.
That funds may not be distributed to any Agency or Center that charges women for services received.
That Agencies or Centers receiving funds must use at least seventy percent (70%) of the funds to provide for the needs of women in an unplanned pregnancy who are committed to keeping or placing their children for adoption, including: a. clothing b. housing c. medical care d. counseling e. food f. utilities g. transportation h. such funds may also be expended on infants awaiting placement with adoptive parents i. the remaining funds (thirty percent 30%) may be used by the Agencies and Centers for adoption expenses, counseling, training, or advertising, but may not be used for administrative expenses, legal expenses, or capital expenditures.
That each Agency or Center must enter into and abide by this written application with the Alabama Pro-Life Coalition Education Fund, Inc. (d/b/a “Choose Life Alabama”).
That any funds that are not used during the year after their receipt by an Agency or Center and which exceed ten percent (10%) of the funds received by that Agency or Center must be returned to Choose Life Alabama, which shall redistribute them to other qualified Agencies or Centers within the County.
That it is the sole responsibility of each Agency or Center to submit annual reports and applications, and that those reports be correct.
That once the deadline for applications and reports are past, the Agency or Center must wait until the following year to re-apply and receive funds.

I and the above-named Agency or Center agree to comply with the requirements of the Choose Life Alabama Fund regarding the “Support Adoption” distinctive license plate, and further certify that the statements above are true and correct are the established policies of my agency, to the best of my knowledge, information and belief. In addition, I and the above-named agency or center agree to abide by the terms of this application as set forth herein and agree to maintain these established policies so that a breach of this application will not occur.

I, the applicant for this grant, warrant the truthfulness of the information provided in this application.

Name Of Agency Or Center*

Electronic Signature*

About Your Organization

Pregnancy Center Directors

Pregnancy Resources

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