Organization Information:

Name

Tax I.D #

Address #

Phone #

Organization Background - Please provide the following information
1. A brief description of the organization's mission
2. The need(s) or problem(s) that your organization works to address, and the population(s) your agency serves, including geographic location, socioeconomic status, race, ethnicity, gender, sexual orientation, age, physical ability, and language.
3. How your organization works to address #2 above.
4. Brief description of the future direction of your organization in the next five years.

Your Information:

Name

Phone #

Email

How did you hear about us?

Executive leadership Information:

Title

Name

Phone #

Email

Grant information:

Is your request for a Special Project, General Operations Fund, or Capital Campaign Funds

How much are you requesting?

When will the funds be used?

Please summarize the purpose of your agency. Briefly explain why your agency is requesting this grant? What outcomes you hope to achieve? And how will you spend the funds if grant is made?

Please describe the program for which you seek funding in more detail:
a) If applying for general operating support, briefly describe how this grant would be used.
b) If your request is for a specific project or capital campaign, please explain the project including:
- A statement of its primary purpose and the need or problem that you are seeking to address
- The proposed staffing pattern for the project, and the names and titles of the individuals who will direct the project.
- Anticipated length of the project.

Project Evaluations:

Please explain how you will measure the effectiveness of your activities. Describe your criteria for a successful program and the results you expect to have achieved by the end of the funding period.

Attachments - Please have small size files ready to upload. If you are unable to attach documents, please contact us (but please submit application)

A chart showing the number of paid full time staff, number of paid part time staff, number of volunteers and Board of Directors. Please include turnover numbers in most recent year of full time staff, officers, and board members.

Most recent financial statement, audited if available. This statement should reflect actual expenditures and funds received during your most recent fiscal year.

Operating Expense Budget for the current and most recent fiscal year.

A list of Government Foundation, Corporate, and Large Donation (greater than $9999.00) Supporters as well as all other sources of income, with amounts, for your current and most recent fiscal year.

Please list the foundations, corporations, and other sources that you are soliciting for funding and, to the best of your knowledge , the status of your proposal with each.

A current expense budget for the project. Please include proposed implementation dates for the project in the title. List each staff line separately and include % of time spent on project. Indicate the specific uses of the requested grant.

A list of all potential and realized sources of income toward the project, actual and prospective with amounts.

A list of your board of directors with their affiliations.

Literature about the organization such as annual reports and brochures

A copy of your most recent IRS letter indicating your agency's tax exempt status, or, if not available, an explanation.

A copy of your most recent IRS Form 990-PF.