ORGANIZATION OVERVIEW SERVICES

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1 KODIAK ISLAND BOROUGH APPLICATION FOR NON-PROFIT CORPORATION FUNDING Application due date: April 24 th, 2015 Please type all responses ORGANIZATION OVERVIEW Organization Name: Physical Address: Mailing Address: Telephone: Fax: Website: Federal Employer Tax ID Number: Contact Person: Is Organization a 501? Yes No Specify Type: If yes, please provide a letter from the IRS signifying the organization s official non-profit tax exemption status. SERVICES Please provide a brief description of the organization s current programs in priority: The Kodiak Island Borough does not fund religious programs. Are the funds being requested going to be used for faith based services? Yes No The Kodiak Island Borough can only fund those services, programs, or items that fall within the powers of the Borough. These municipal powers include: 1. Education 8. Parks and Recreation 2. General Administration and Finance 9. Economic Development 3. Tax Assessment and Collection 10. Animal Control 4. Planning and Zoning 11. Fire Protection and First Responder 5. Emergency Services Planning 12. Emergency Medical Services 6. Community Health 13. Road Maintenance and Construction 7. Solid Waste Collection and Disposal 14. Street Lighting Explain how the organization s services, programs, or items that fall within the powers of the Kodiak Island Borough. Are the organization s services delivered island-wide? Yes If not, please list the service delivery area: No Non-Profit Application (Rev. 02/2015) Page 1 of 9

2 Are the organization s services open to ALL residents of Kodiak Island Borough? Yes If not, please explain why: No Is your organization tourism related? Yes No If yes, please describe the tourism aspects of the organization. How does the organization collaborate with other local non-profits? How does the organization use volunteers? Is the organization audited or reviewed? Yes FINANCIAL INFORMATION If yes, please attach latest audited or reviewed financial report. No If the organization is not audited or reviewed, please attach the organization s latest annual financial statements, including a profit and loss statement and a detailed balance sheet. Organization s fiscal year dates: Non-Profit Application (Rev. 02/2015) Page 2 of 9

3 Funding request total amount: FUNDING REQUEST Specific programs, services, or item(s) in the organization s mission to be funded: Start date: Number of people served: Work plan/justification (limit response to 500 words): End date: Non-Profit Application (Rev. 02/2015) Page 3 of 9

4 Measure of success or expected results (limit response to 250 words): BUDGET FOR REQUESTED GRANT Salary Wages Fringe Benefits Consultant Fees Travel Supplies/Materials Printing/Copying Telephone/fax Postage/delivery Advertising Rent Utilities Other (define) Total Non-Profit Application (Rev. 02/2015) Page 4 of 9

5 OTHER FUNDING SOURCES List amount of funds the organization received from other sources for this past fiscal year: Federal State City of Kodiak Other Grants Donations Gaming Permit Activities Other (defined) Total If you receive state or federal grants, list the percentage and amount of local match that was required for each grant the organization received in the prior fiscal year. Federal: MATCHING GRANTS Grant Amount Matching Amount Match % State: Other: Total: Did the organization receive funding from the Kodiak Island Borough during the last fiscal year (July 1, 2014-June 30, 2015)? Yes No If yes, please complete the attached grant report and submit it with this application. Please describe briefly any fundraising activities the organization has conducted in Kodiak over the past eighteen (18) months and the results of those activities. Signature Printed Name Title Date Non-Profit Application (Rev. 02/2015) Page 5 of 9

6 KODIAK ISLAND BOROUGH GRANT REPORT PAGE 1 OF 2 Please complete this report based on funds received from the Kodiak Island Borough during the period of July 1, 2014 through June 30, Organization: Grant Amount Amount Expended Year to Date Balance Accomplishments with grant funds using measures indicated in application (limit response to 500 words): Non-Profit Application (Rev. 02/2015) Page 6 of 9

7 KODIAK ISLAND BOROUGH GRANT REPORT PAGE 2 OF 2 Direct Costs Salary Wages Fringe Benefits Consultant Fees Travel Supplies/Materials Services Other (defined) BUDGET Budget Actual Total Direct Costs Indirect Costs Donated Time Donated Materials Total Indirect Costs Total Costs If you have not expended all funds, please describe how and when you intend to spend the balance. Signature Printed Name Title Date Non-Profit Application (Rev. 02/2015) Page 7 of 9

8 DID YOU ATTACH THE FOLLOWING DOCUMENTS? List of Board Members and Officers Letter from the IRS signifying organization s official non-profit tax exemption status Organization s Mission Statement Copy of the organization s long range plan such as a business plan, strategic plan, or development plan Attach latest annual audited financial report or financial review (if your organization is audited or reviewed) Attach organization s latest annual financial statements, including a profit and loss statement and a detailed balance sheet (if your organization is not audited or reviewed) Attach grant report (page 6 and 7) and submit it with this application if your organization received funding from the Kodiak Island Borough during the last fiscal year (July 1, 2014 June 30, 2015). Submit applications to: Kodiak Island Borough Manager's Office Attn: Meagan Christiansen 710 Mill Bay Road, Room 230A Kodiak, AK via facsimile: via mchristiansen@kodiakak.us Non-Profit Application (Rev. 02/2015) Page 8 of 9

9 2015 TO 2016 RATING CRITERIA FOR KIB NONPROFIT GRANT APPLICATIONS Applications will be ranked by the Assembly nonprofit subcommittee and final rankings will be provided to all Assembly members. 100 points possible per application. Category Points Request falls within the powers of the KIB 20 Organization s track record of success including past Borough funding 15 Provided requested financial and organizational information 10 Specific as to how funds will be used 10 Clearly identified benefit to the community and benefit to KIB citizens and number of citizens 10 served Cost vs. benefit 10 Organization s fiscal and management capacity 10 Request fits the organization s mission 5 Active board and experienced staff to carry out request 5 Organization funded by a variety of sources 5 Total 100 Non-Profit Application (Rev. 02/2015) Page 9 of 9