Grant Applica,on Form

Transcription

1 Grant Applica,on Form The Henry T. Nicholas, III Founda,on is a California charitable trust organized and operated exclusively for charitable, scien,fic or educa,on purposes within the meaning of Internal Revenue Code sec,on IRC 501(c)(3). Important Notes for this Applica3on: 1. This form must be completed in its en,rety and must accompany the grant proposal. Applica,ons for funding are only considered complete if they include this form, a grant proposal, and a copy of your IRS tax exemp,on lemer and grant suppor,ng documents. 2. Your grant proposal must use the format outlined on page 5. Please only submit proposals that strategically relate to the Henry T. Nicholas, III Founda,on s mission. GRANT REQUEST Amount Requested: $ This request is for: General opera,ng support Capital Program/project,tle Organiza3onal Informa3on: Organiza,on s Name: Address, city, state & zip code: Organiza,on s URL: Applicant Contact Name & Title: Henry T. Nicholas III, Foundation Grant Application Form Version

2 Applicant s Phone: Total Organiza,onal Budget for current year $: Year of Incorpora,on Staff Composi3on in Numbers Paid Full,me Paid Part,me Volunteer Intern Board of Directors Other Organiza3onal Informa3on (con%nued) Is your organiza3on exempt under the Sec3on 501(c)(3) of the Internal Revenue Code? Yes Date of Exemp,on Ruling: (Include copy of exemp,on lemer) No Note: The Founda.on cannot fund any organiza.on that is NOT a 501(c)(3) Is your organiza3on a public charity by virtue of its being an organiza3on described in Sec3on 509(a) of the Internal Revenue Code? Yes Classifica,on: IRC 509(a)(1) IRC 509(a)(2) IRC 509(a)(3) If your organiza,on is an IRC 509(a)(1) or a IRC 509(a)(2), will the amount of funds requested in this applica,on adversely affect your organiza,on s status as a publically supported organiza,on? Yes No Henry T. Nicholas III, Foundation Grant Application Form Version

3 Please es,mate the percentage of total qualifying public support that your organiza,on has received over its past two fiscal years from: o Contribu,ons from the general public: % o Grants from governmental units: % o Grants from other chari,es: % o Receipts from exempt func,on income % o Investment income % No Classifica,on is: Primary service category of organiza3on Arts & Culture Health & Human Services Military Services Educa,on Civic/ economic development Sports & Recrea,on Other: Geographic service areas: Orange County, CA Los Angeles County, CA Riverside County, CA Statewide California Outside California Na,onwide Interna,onal Organiza3onal Informa3on (con%nued) Henry T. Nicholas III, Foundation Grant Application Form Version

4 Summarize the organiza3on s mission (2 3 sentences): Funding Request: Summarize the purpose of your request (1 5 sentences): List other private and public funding sources for this request. There are no other funding sources for this request. Funding Sources to date Amount Date received Henry T. Nicholas III, Foundation Grant Application Form Version

5 Funding Sources to date Amount An%cipated receipt date Funding Request (con%nued): Does this grant qualify for matching funds with another organiza3on? Yes No Time Frame in which the funds will be used: From to Is this a mul3 year grant request? Yes, for years No Note: The Founda%on will consider mul% year grant requests but will not necessarily award mul% year funding. Program/project budget $ Percent request represents: % The informa%on provided in this applica%on and proposal is furnished in considera%on of a proposed grant, and it is intended that it may be relied upon by the Henry T. Nicholas, III Founda%on as of this date. The Henry T. Nicholas, III Founda%on is under no obliga%on to fund this request at this %me. By submiing this request, the applicant and the Henry T. Nicholas III, Foundation Grant Application Form Version

6 organiza%on agree to disclose informa%on about the grant project as reasonably requested from the Founda%on, including a possible pre grant interview or site visit, as the Founda%on considers the grant proposal. Due to the requirements of the Founda%on for the due diligence process, failure to provide the requested informa%on may result in rejec%on of the grant proposal. The applicant will no%fy the Henry T. Nicholas, III Founda%on of any material change in the informa%on provided herein. Signed: (Designated grant applicant) Name: Date: SEE NEXT PAGE FOR PROPOSAL GUIDELINES. A GRANT PROPOSAL MUST BE SUBMITTED WITH THIS APPLICATION FORM AND A COPY OF YOUR ORGANIZATION S TAX EXEMPT LETTER. Grant Proposal Guidelines Henry T. Nicholas III, Foundation Grant Application Form Version

7 Proposal Narra3ve: Please provide the following informa%on to the Henry T. Nicholas, III Founda%on in this order. Do not use more than 4 single spaced pages, exclusive of a\achments. Please staple, do not bind your applica%on. A. Background 1. Organiza,on s mission, history, overall goals and/or objec,ves 2. Descrip,on of current programs and ac,vi,es, emphasizing major achievements of the past two years. 3. Descrip,on of any past work or rela,onships with the Henry T. Nicholas III, Founda,on. B. Purpose of Funding Request 1. Descrip,on of how the grant request relates to the mission of the Henry T. Nicholas III, Founda,on. 2. If applying for a general opera,ng support grant, briefly state how this grant could be used. 3. If applying for a specific project or capital campaign, please provide the following informa,on: The needs or problems that this effort will address and the popula,on that is will be served. Descrip,on of how the project addresses the above iden,fied needs. Descrip,on of the goals and objec,ves and,metable for achieving these. If for a program, explain the implementa,on, methodology and staffing of program. Outline any collabora,on with other organiza,ons (include both funding, support and service partners) and include a descrip,on of their roles. If for a program, explain if and how it can be supported beyond an ini,al grant. Addi,onal outcomes and benefits of funding the request, if any (i.e. matching funds or tax credits). 4. Any deadlines or condi,ons to funding this request. C. Evalua3on 1. Explain how you will measure the effec,veness of your ac,vi,es. 2. Describe your criteria for success. 3. Describe the results you expect to have achieved by the end of the funding period. Henry T. Nicholas III, Foundation Grant Application Form Version

8 Required A`achments: Please provide in the following order. A. Finances 1. Program budget (with narra,ve or descrip,on, if applicable) with line items, no,ng where requested funds would be used. 2. If a mul, year grant request, include mul, year program budget. 3. If a capital campaign, provide capital budget and list of campaign commimee members. B. Suppor3ng Materials 1. Grantee Report (if program previously funded from other sources). 2. Latest annual report or summary of organiza,on s prior year s ac,vi,es. 3. If the requested project is a collabora,on with other organiza,ons, include lemers of agreement. 4. A,metable outlining project implementa,on and/or achieving goals of this request. Henry T. Nicholas III, Foundation Grant Application Form Version