Per Lilly s request, they will accept requests from the Bloomington and Indianapolis campuses only. The College of Arts and Sciences and the Kelley School may submit multiple requests per funding round. All other units are limited to one request per funding round. All requests will be submitted electronically by IUF IU ERA: Routing Form - Tracking Number (required only for requests moving to full proposal): Note: Schools / Units to complete sections in red on the application. Eli Lilly and Company Foundation Grant Application Organization Name Indiana University - (CAMPUS) Street Address 950 North Meridian Street, Suite 250 City Indianapolis State IN Zip Code 46204 Federal Tax ID 35-6001673 1
Tax Status 509(a)2 Phone (317)278-5648 Fax (317)274-8818 Organization's website address www.indiana.edu / Organization's total annual budget (Include amount only. MUST match figure on budget template) Background/Mission Statement Organization Type Education Contact Information Executive Director/CEO/President Prefix Dr. First Name Michael Middle Initial A. 2
Last Name McRobbie Suffix Title President Office Phone (317)278-5648 Extension Office Fax (317)274-8818 E-mail kellsmit@indiana.edu Primary Contact for this application (if different from above) Prefix Ms. First Name Barbara Middle Initial S. Last Name Bosch Suffix 3
Title Executive Director, Corporate and Foundation Relations, Indiana University Foundation Office Phone (317)278-5648 Extension Office Fax (317)274-8818 E-mail bsbosch@indiana.edu Request Information Program or Project Title Program or Project Description Please limit your response to 100 words or less. Program or Project Total Budget (Include amount only. MUST match figure on budget template) Amount you are requesting from Eli Lilly and Company Foundation (Include amount only. MUST match figure on budget template) Describe the number and frequency of payments that you are requesting from Eli Lilly and Company Foundation 4
example: annual payments spread over three years Does your organization serve a community in which a Lilly plant site is located? Please select the appropriate plant site location or "none of the above" Lilly Corporate Center If Lilly Foundation does not fund the entire budget for this program or project, please describe other sources for the remaining budgetary needs. Project Start Date Month / Day Year (Month / Day / Year) Note: June submissions cannot start before January 1 of the following year. December submissions cannot start before July 1 of the following year. Project End Date (Month / Day / Year) Please describe the primary purpose of the program or project including the goals, objectives, and how it addresses a particular need. What is your target audience? How will you measure success? How will the Lilly Foundation be recognized for its support? 5
I confirm that this project/program is consistent with the organization's tax exempt purpose. Yes Geographical area served by the program. If you select "International," please specify the countries included within the project scope in the program or project description field above. United States-Indiana Program Area Education-Colleges and Universities Population Served choose up to 3 from the list below: 1. 2. 3. Students Chronically Ill Crime / Abuse Victims Developmentally Disabled Disadvantaged Youth Disaster Victims Economically Disadvantaged General Population Physically Disabled Other What age group(s) will be served by this program? choose up to 3 from the list below: 1. 2. 3. Children (6-12) Young Adults (13-18) Adults Mature Adults (55+) 6
All Age Groups What gender(s) will be served? choose one from the list below: 1. All genders Females Males Ethnicity choose up to 3 from the list below: 1. 2. 3. International Citizens African American Asian American Caucasian Hispanic / Latino Native American All Ethnicities What type of support are you seeking? choose one from the list below: Challenge Grant Endowment General Operating Memorial Project / Program Scholarship Fellowship Technical Assistance Other Has this proposal been requested by Lilly staff? (If so, who and when): Have conversations been held with Lilly staff regarding the proposal (If so, who and when): 7
Attachments for initial review: UNIT to PROVIDE Current annual organization operating and project budget [must be submitted using the Eli Lilly and Company Foundation Grant Application (2009) Budget template.xls] Budget explanation: detailed explanation for each income / expense category on Lilly s template ------------------------------------------------------------------------------------------------------------------------------------------ Attachments for full proposal review: UNIT to PROVIDE Current annual organization operating and project budget [must be submitted using the Eli Lilly and Company Foundation Grant Application (2009) Budget template.xls] Advisory Board list Other attachment (please contact Kelly Smith if you have an additional document that you would like to include with the online application). Note: only one additional attachment may be included Note: Acceptable electronic formats for upload include: Microsoft Word (.doc), Microsoft Excel (.xls) or Adobe Acrobat (.pdf). Lilly s system is unable to access or recognize any other file extensions, such as.bmp,.gif,.jpg,.tif or.wma. IUF will PROVIDE: IU Board of Trustees list Most recent financial statements (audited if available) for IU IRS determination letter and any updates or changes to that letter 8