Start: 11/20/2017 Deadline: 01/16/2018 Grace Period: None Application Fee (USD): $0.00? Applications: None Share: https://impact100westchester.slideroom.com/#/perm Letter of Inquiry- 2018 Grant Cycle Forms Eligibility Guidelines 1. Please confirm that you have reviewed our Eligibility Guidelines in detail, which can be found on our website at: http://impact100westchester.org/eligibility/ Choose one of the following: Organization 1. Legal name of organization applying for the Impact100 Westchester grant: The name must match the 501(c)(3) certificate unless there is a fiscal sponsor. 2. Site address where the main activities are located: 3. Mailing address, if different from site address: 4. Website: 5. Executive Director Name: Page 1 of 6
6. Executive Director Email: 7. Executive Director Phone: (xxx) xxx-xxxx 8. Federal Tax ID: Enter the Federal Employer Identification Number (EIN) (##-#######). 9. When did the organization receive it's 501(c)3 status? Enter the date (mm/dd/yyyy) stamped on the organization's 501(c)(3) Determination Letter. If only a month and year are indicated, simply use the 1st of the month. 10. Has the organization's 501(c)3 status been revoked or modified within the past 3 years? 11. Have you received a grant from Impact100 Westchester in the past 36 months? Please choose one of the following: 12. When does your Fiscal Year end? Provide your fiscal year end date in 2017 in mm/dd/yyyy, e.g. 06/30/2017 13. Is your organization applying for this grant under its own 501(c)(3)? If you are applying under a fiscal sponsor, answer "No" and explain below. 14. Do you have at least three years of independently reviewed or audited financial statements? 15. In the past 3 years, has your independent accountant or auditor expressed any concerns regarding your organization's financial health and/or viability? 16. Based on your most recently filed Form 990, what is your organization's Total Revenue? Form 990, Part I line 12 (Current Year). Please enter the amount as a whole number without commas. Page 2 of 6
17. What % of your organization's Total Expenses in your most recently filed Form 990 goes towards Program Services? Form 990 Part IX Line 25 "Column B" DIVIDED by Line 25 "Column A." Enter this number as a decimal and include a leading zero. For example, enter "0.85" instead of 85% Mission/Major Programs 1. Describe the major programs that support your organization's mission. 1800 character limit, including spaces. 2. Provide your organization's mission statement and brief history. 2000 character limit, including spaces. 3. What makes your organization unique? 500 character limit, including spaces. 4. What are your top five funding sources? For each donor, indicate Funding Source or Donor Name, Amount Donated in Fiscal Year 2017 and Expected Amount for Fiscal Year 2018 Project Overview 1. Project Title: Enter the title of the project. 2. What is the nature of this project? Choose one of the following: 3. Project Overview Provide a clear, brief summary of the project. 1000 character limit, including spaces. 4. Describe the target population. 500 character limit, including spaces. Please include number served, demographics, target market, residence/location of beneficiaries, etc. Page 3 of 6
5. Describe your project's overall goal and objectives. 1500 character limit, including spaces. 6. Where will activities for this project take place? 80 character limit, including spaces. 7. How will this project transform your organization? 1000 character limit, including spaces 8. How will this project transform the lives of the target population? 1000 character limit, including spaces 9. What is your plan for sustaining this project after the funding from Impact100 is over? 1000 character limit, including spaces 10. Project Budget ($): PLEASE RETURN TO THIS QUESTION AFTER THE GRANT AMOUNT HAS BEEN ANNOUNCED IN JANUARY 2018. Enter whole numbers, e.g. 85000 (do not use commas) 11. When do you expect the project to start? (If the project for which you are requesting Impact100 funds is part of a larger project, please indicate when the specific Impact100 portion of the project will start) (mm/dd/yyyy) 12. Describe the project logistics, including timing, key personnel, facilities and other resources required for the project to be successful. 1800 character limit, including spaces. 13. Will this project involve other organizations? 14. According to your Project Budget Form, how much of the Impact100 Westchester grant will be covering Allocated Overhead? PLEASE RETURN TO THIS QUESTION AFTER THE GRANT AMOUNT HAS BEEN Page 4 of 6
ANNOUNCED IN JANUARY 2018. Allocated Overhead includes: general facility costs, utilities, insurance, "corporate" staff salaries (such as: senior management, legal, human resources) and other expenses which are allocated to the project but which will be incurred by your organization whether or not the project goes forward. Enter whole numbers without any commas. 15. Provide a projected timeline of when you will need the Impact100 funds Describe the anticipated timing (e.g. 50% August 2018, 50% November 2018, project expected to be complete by 11/30/2018) 16. Project Contact Name: 17. Project Contact Title: 18. Project Contact Phone: (xxx) xxx-xxxx 19. Project Contact Email: LOI Authorization 1. Executive Director Certification: By typing the Executive Director's name below, you are certifying that the Executive Director attests to the accuracy and completeness of this Letter of Inquiry. Attachments 1. Form 501(c)(3) * Please upload your 501(c)(3) Determination Letter confirming that you are a charitable organization exempt from Federal Income Taxes. 2. Form 990 * Please upload your most recently filed IRS Form 990 together with all supporting schedules (note: SlideRoom has a 10 MB size limit for PDFs; you may need to compress your file before uploading; see Grant FAQs under Apply for a Grant on our website for further information) Page 5 of 6
3. Project Budget Form* * Download Project Budget Form from www.impact100westchester.org/grantapplicationsforms, complete the Excel Spreadsheet, convert to PDF form and upload to Slideroom. DO NOT UPLOAD YOUR FINAL VERSION OF THE PROJECT BUDGET FORM UNTIL AFTER THE GRANT AMOUNTS HAVE BEEN ANNOUNCED (JANUARY 8, 2018). 4. Fiscal Year 2018 Operating Budget * Please upload your annual Operating Budget for the Fiscal Year ending during 2018. Please include year-to-date actuals versus budget if available. 5. Most Recent Fiscal Year Stmt w Accountant's Report * Please upload your 2017 Fiscal Year Financial Statement, if available, including accountant's report. Otherwise, upload your 2016 Fiscal Year Financial Statement and email treasurer@impact100westchester.org with the date that you expect the 2017 Fiscal Year Financial Statement to be available. Applicant instructions: PLEASE UPLOAD YOUR DOCUMENTS IN PDF FORM and remember to remove any password protection. Refer to Grant FAQs under Apply for a Grant on our website for guidance on PDF size limitations. Thank You! Page 6 of 6