CREATE Financial Waiver Application | Colorado Rural Health Center

Below is the CREATE Application. If you’re seeing this page, you should have already completed the pre-application steps and received an application number. If you have not, please contact us at web@coruralhealth.org . You must have an application number in order for your application to be considered for funding.

For examples of required attachments, click below:

Balance Sheet Example

Budget Example

Income Statement Example

CREATE Financial Waiver (CURRENT)

CREATE Financial Waiver Application

Step 1 of 2

Legal Entity Name*
Grant Number*

You must have an application number in order to proceed. Application numbers are provided by CRHC staff after you have completed all steps at the link below. If you do not have an application number, your application will not be considered for funding. https://coruralhealth.org/create/create-contact-info
Doing Business As (DBA)
Federal Tax ID #*
Contact Title*
Grant Contact Name*
Grant Contact Email*
Daytime Phone*
Mobile Phone
Fax
Match Information
Proposed Match (%)*
Total App $ Amount*
Proposed Entity Match*
Proposed CREATE Match*
Narrative Questions
Describe the financial situation of your entity that indicates the need for a waiver (The applicant is responsible for justifying their need):*
Describe your entity’s capital expenditures proposed in your financial documents attached. Also, provide the purpose for cash and cash equivalent accounts (both restricted and unrestricted).*
Is your entity part of a larger organizational budget?*
Provide details that clarify the financial statements attached. Specify where your operating results can be found if they are reported as part of a larger organization (example: department of a city government).*
Describe any austerity measures (pay cuts, furloughs, layoffs, cuts in benefits, service reductions, programs discontinued, etc.) that have been implemented to reduce costs.*
Has this entity applied for other grants or conducted fundraising activities for the express purpose of providing match for this program?*
Describe efforts towards gaining matching funds, as well as how successful those efforts were.*
Authorized Agent
First Name*
Last Name*
Title*
Daytime Phone*
Date*
MM slash DD slash YYYY
Signature of Authorized Agent*

By typing your name in this box, you indicate that you are the authorized agent.

Save and Continue Later

CREATE Financial Waiver (CURRENT)

Step 1 of 2

Match Information

Narrative Questions

Authorized Agent

Attachments

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