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Date Submitted: |
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1. General Information About Your Organization |
Organization Name: |
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State: |
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Date Established: |
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Zip Code: |
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Address: |
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Telephone: |
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City: |
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Fax: |
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Contact Person: |
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Email Address: |
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| Officers, Directors or Trustees of the Organization: |
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| What percentage of your board contributes financially to your organization? |
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| General Objective of your Organization: |
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Number of individuals of Families Served by your Organization? |
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Are you a new organization? |
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Is the requested grant for a new program? |
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Number of paid full time employees: |
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Number of paid part time employees: |
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Will this grant involve additional employees? |
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If yes, how many? |
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Is your organization a United Way Agency? |
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If yes, is this program funded by United Way? |
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Is your organization associated with any religious organization? |
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If so, what organization? |
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Is your organization a 501(c) (3) organization? |
No (Fax us a copy of your IRS Determination Letter) |
2. Details of Grant Request |
| Briefly describe the project or program for which funds are requested. |
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Grant Amount Requested:$ |
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One time only?(One time only refers to requests where the organization will not come to the foundation for funding for the project in the future. If you feel you will come to the foundation in future years, please indicate this below.) |
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Date:
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Amount:
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Date:
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Amount:
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Date:
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Amount:
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Date:
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Amount:
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Date:
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Amount:
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Date:
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Amount:
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Date:
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Amount:
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Date:
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Amount:
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| Geographic Area Grant Will Serve: |
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| Number of Individuals/Families Grant Will Serve: |
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| Other Funding Sources Applied To For This Project (Source/Amount): |
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| Sources of Firm Pledges and Commitments to Date (Source/Amount): |
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| Have you been refused any funding for this program? |
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| If yes why? |
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| If this project will be continuing one, explain in detail the source of funds for operations in future years: |
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| If the Community Foundation of Monroe County does not approve your request for a grant, what alternative plan would you probably follow? |
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3. Financial Record of Organization |
| Sources of Funds in Previous Years: |
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| Itemize the complete cost of the program or project for which you are making a grant application in the area below.(Item/Amount) |
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| Itemize the sources from whom you hope to receive funds for this project or program.(Source/Amount) |
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| Other Assets Available for the program or project (Endowments, Reserves, etc): (Asset/Amount) |
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| Have you applied for, or are you contemplating applying for, State or Federal funds? |
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| If yes, explain fully, including the amounts that may be available from these sources:(item/Amount) |
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| Previous Grants your organization has received from the Community Foundation of Monroe County:(Project and Date/Amount) |
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4. Project Details |
| What led you to seek funding for this project (i.e. Community Support, Research, Fact-Finding, etc.)? |
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| Please explain the need for your project and its relevance to improving the quality of life in Monroe County: |
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| Have similar projects been undertaken by other organizations in the community?: |
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| How will you evaluate the success of your project? |
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| Is there any other information you wish to include that is pertinent to your project? |
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