GRANT REQUEST

Name of Applicant*

Email*

EIN*

Address

Total Proposed Project/Program Budget*

Amount Requested

Program Name*

Duration
From* to*

When are funds needed?

Nature of Request
CapitalProjectOperatingProgramEndowmentOther

Chief Staff Officer/Title

Phone

Contact Person/Title

Phone

Board Chairperson/Title

Dates of organization's fiscal year

Organization's total operating budget for past year

Organization's total operating budget for current year

Does the organization have federal tax exempt status?
YesNo

If no, please explain

Requestor Name*

Title*

Upload Word document based on requirements below (max 2 MBs):

Please upload the following information (in the form above) in the order presented below.

Project/Program Purpose/Objective

Describe in an introductory letter the purpose/objectives of program; amount requested and how funds will be utilized

Organizational Information

IRS determination letter of 501(c) 3 status; Provide a brief summary of the organization's:

• Mission, goals, programs, and major accomplishments, success stories and qualifications
• Line item operating budget; audited statement; tax return
• Names of governing board members
• Explain the significance/scope of the program and why your organization is qualified to carry it out.
• Describe the expected outcomes and the indicators of those outcomes.
• Describe the evaluation process and how the results will be used.
• Document the size and characteristics of the population to be served.
• Outline the strategy/methodology and timeline to be used in the development and implementation of the program.
• Strategic Partners or alliances in delivery of service.

Funding Considerations

Describe plans for obtaining other funding needed to carry out the project/program or organizational goals (including amounts requested of other funders). If the project/program is expected to continue beyond the grant period, describe plans for ensuring continued funding after the grant period. List the top five funders of this project (if applying for a program grant) or organization (if applying for general operating support) in the previous fiscal year, the current year, and those pending for the next fiscal year.

Objective

Specific program description; type of persons reached; age; number of persons reached; social and economic status; geographic location (priority given to Broward County and Florida).

Maximum 5 MB
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