COMMUNITY FUNDING PROGRAM FISCAL YEAR APPLICATION FORM INSTRUCTIONS COVER SHEET/PAGE 1-2

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1 Finance COMMUNITY FUNDING PROGRAM FISCAL YEAR APPLICATION FORM INSTRUCTIONS The following information will assist you in completing the community Funding proposal form. Applications are due by Nov. 17, Applications not received by the due date will be ineligible for fiscal year funding. Applicants who submit incomplete applications will have five working days from time of notification to correct any deficiencies in order to receive further evaluation. Answer all of the questions included with these instructions. If you need additional space to respond to questions, you may use an additional page labeled Continuation of #, i.e., Continuation of 5b. If you have questions regarding the Community Funding process, please contact Nicole Casados at or COVER SHEET/PAGE 1-2 Agency Name: Provide the name of the primary agency who will carry out the proposed activity. Program Name: List the program name, if the grant requested intends to support a specific program. Service Category/Type: Indicate which of the eligible categories best describes the type of service your program will be providing. If your program falls under more than one category, indicate the one that best describes the proposed activity. Please mark only one category. Service Population: Indicate the total number of individuals OR families serviced by your program for fiscal year Please also indicating separately the number of those served that were Menlo Park residents for that same year. Organizational Structure: Provide the information requested regarding your organization. Fiscal: Please complete all information requested. PAGES To give the City Council Subcommittee an overall picture of your agency, please provide a brief statement of your agency purpose. 2. Clearly describe how your agency will use the funds if awarded. 3. Describe the reasons that you have chosen to request financial assistance from

2 the City of Menlo Park. 4. Describe how this program benefits the Menlo Park community and provide supporting documentation as evidence of stated results. The committee will use this evidence to award points. 5. Since resources are becoming more limited, collaboration and coordination among recipient agencies is critical. Therefore, please describe ways in which your agency collaborates, coordinates and networks with other agencies. Furthermore, if there are currently other agencies providing similar services, please describe how your agency collaborates and works with that agency to avoid an unnecessary duplication of services. PAGE 6-7 Information on the overall financial status of applicants, in combination with program information, is extremely helpful to the proposal review process. Therefore, please provide the information requested regarding your projected revenues and expenditures for the current funding year (July 1, June 30, 2018) and your expenditures from the previous funding year (July 1, June 30, 2017). You will note that we are requesting information as it applies to both the specific program (if applicable) for which you are requesting funding and the entire agency. PAGE 8-9 Page 8 is to certify information provided and provide signature. Page 9 is evaluation criteria for ranking the priority of programs for funding. Return applications by Nov 17, 2017, to: City of Menlo Park City Manager s Office ATTN: Community Funding Program 701 Laurel St. Menlo Park, CA nscasados@menlopark.org

3 CITY OF MENLO PARK COMMUNITY FUNDING PROGRAM APPLICATION FISCAL YEAR Page 1 AGENCY NAME PROGRAM NAME (If Menlo Park grant request intends to support a specific program) ADDRESS MAILING ADDRESS (if different) TELEPHONE CONTACT PERSON SERVICE CATEGORY/TYPE (Please indicate a category and describe type of service to be provided) ( ) DISABLED ( ) EMERGENCY ASSISTANCE ( ) SENIOR ( ) YOUTH/TEENS SERVICE POPULATION Total # of individuals/families served in prior fiscal year Total # of Menlo Park residents/families served in prior fiscal year Comments:

4 COMMUNITY FUNDING PROGRAM APPLICATION, FY Page 2 ORGANIZATIONAL STRUCTURE Nonprofit Status: ID # Year Incorporated A. Number of members on governing board B. How often are director s meetings held? C. How many employees? Full Time? Part Time? D. How many volunteers? How many volunteer hours per month? FISCAL FY Community Funding request from Menlo Park $ This request represents % of agency projected FY income FY City of Menlo Park Community funding allocation $ FY funding received from other cities $ Previous Fiscal Year funding received from Menlo Park $

5 COMMUNITY FUNDING PROGRAM APPLICATION, FY Page 3 1. Please provide a brief statement of your agency purpose. 2. Describe how your agency plans to use the requested funding if awarded.

6 COMMUNITY FUNDING PROGRAM APPLICATION, FY Page 4 3. Describe your reasons for requesting financial assistance from the City of Menlo Park. 4. Describe how your services or specific program benefits the Menlo Park Community and how it may be uniquely positioned to fill an identified community need. Attach supporting documentation or other evidence of stated results which demonstrate a change in the community caused by the services or program for which you are requesting funds.

7 COMMUNITY FUNDING PROGRAM APPLICATION, FY Page 5 5. a) Describe ways in which your agency collaborates, networks and coordinates activities and/or services with other agencies. b) If there are other agencies providing the same type of service(s) as yours, please describe how your agency collaborates and works together with the other agency(s) to avoid unnecessary duplication of services.

8 COMMUNITY FUNDING PROGRAM APPLICATION, FY Page 6 REVENUES AND EXPENDITURES (July 1 - June 30) Agency Name PROJECTED REVENUES AND EXPENDITURES BUDGET YEAR (Current Funding Year) PROGRAM (if grant intends to support a specific program) AGENCY REVENUES FY (by funding source) $ AMOUNT % OF TOTAL BUDGETED REVENUE $ AMOUNT % OF TOTAL BUDGETED REVENUE City of Menlo Park All other sources Total 100% 100% PROGRAM (if grant intends to support a specific program) AGENCY EXPENDITURES FY $ AMOUNT % OF TOTAL BUDGETED EXPENDITURES $ AMOUNT % OF TOTAL BUDGETED EXPENDITURES Direct Service Costs Administrative Costs Total 100% 100% The requested grant from Menlo Park of $ would be % of the total Agency operating budget.

9 COMMUNITY FUNDING PROGRAM APPLICATION, FY Page 7 EXPENDITURES FROM BUDGET YEAR (Prior Funding Year) PROGRAM (if grant intends to support a specific program) AGENCY EXPENDITURES FY $ AMOUNT % OF TOTAL BUDGETED EXPENDITURES $ AMOUNT % OF TOTAL BUDGETED EXPENDITURES Direct Service Costs Administrative Costs Total 100% 100%

10 COMMUNITY FUNDING PROGRAM APPLICATION, FY Page 8 CERTIFICATION The applicant hereby proposes to provide the services in accordance with the Community Funding policy of the City of Menlo Park. If this proposal is approved and funded, it is agreed that relevant federal, state and local regulations and other assurances as required by the City of Menlo Park will be adhered to. Furthermore, as the duly authorized representative of the applicant organization, I certify that the applicant is fully capable of fulfilling its obligation under this proposal as stated herein. Furthermore, applicant certifies that the agency making this application is: 1) Nonprofit, 2) Tax exempt, 3) maintaining accounting records in accordance with generally accepted accounting practices and has had an independent audit with the last two years, and 4) incorporated in the state of California, and has complied with all applicable laws and regulations. This application and the information contained herein are true and correct and complete, to the best of our knowledge. By: Executive Director Date: Organization Name President of the Board on behalf of the board of directors Date:

11 COMMUNITY FUNDING PROGRAM APPLICATION, FY Page 9 AWARD CRITERIA (used for determining priority for funding, not funding amounts) Criteria Potential points Admin <15% / city contribution, 20% or < 10 Previous funding recipient 5 Documentation of results 20 Impact on Menlo Park (# MP participants served, $/MP participant, demonstrated community change) Documented community need not filled by City 10 Unduplicated service / collaboration if duplicated 15 Priority use of tax dollars per City Council goals 20 Total possible points Compliance with annual reporting requirement if funds were granted prior FY Y= 0 N= -15pts

12 City Manager's Office October 23, 2017 Name Organization Address City, State ZIPEmpty RE: Notice of FY Community Funding Grant Availability Empty Dear XXXXX: The City of Menlo Park invites your organization to submit a request for participation for the FY Community Funding Grant Program. The purpose is to provide financial support to local nonprofit agencies whose programs respond to the human service needs of Menlo Park residents. This funding intent is to subsidize the recipient agency, not be the sole support of any organization. All recipients of financial assistance grants enter into a contractual agreement with the City detailing the specific objectives the grant funds will accomplish. Grant recipients must fully expend all funds by June 30, Using the Community Funding Program guidelines, the City Council will allocate the limited resources to invest in community needs. Therefore, please note that your request is for consideration only and in no way guarantees funding for your agency. All necessary information, instructions and forms for submitting a grant application are included in this packet. The City Council has appointed a subcommittee to review all applications. City staff will notify you if an interview is necessary and when the City Council will discuss and make their final funding decisions. Applications are due no later than 5 p.m. Nov. 17, Current Recipients If you have received a community funding grant from the City last fiscal year (July 1, 2016 June 30, 2017) your organization is required to also submit the following information to the City: A narrative report describing the activities funded last fiscal year under the agreement; said report shall include the total number of direct beneficiaries with demographic information regarding ethnicity, age and other data, and City of Menlo Park 701 Laurel St., Menlo Park, CA tel

13 2 A detailed financial statement and analysis from last fiscal year setting forth the foregoing information. If you have not already done so, please submit your narrative report and audited financial statement for fiscal year to the City as soon as possible or your application will not be considered. If you need any assistance, please contact Nicole Casados at or nscasados@menlopark.org. Sincerely, Kirsten Keith Mayor City of Menlo Park 701 Laurel St., Menlo Park, CA tel