ISSUE-SPECIFIC GRANT PROGRAMGRANT APPLICATION

section one

Organization Information

Applicant Organization:
Mailing Address:
City: / State: / Zip:
Telephone: / Fax: / County:
Website:
Executive Director: / Email:
Application Contact(if different): / Email:
Title (if different): / Phone:

financial and request information

Issue-Specific Fund Applying To
Organization’s Budgeted Expenses for Current Year (give fiscal year end mm/dd/yy) / $
Organization’s Major Funding Sources by percentage (e.g., United Way, local foundations, governmental entities, etc..)
Program/Project Title
Total Budget for this Program/Project / $
Amount of this request / $
Timeframe for amount requested
Anticipated Project Start Date
Total Number of people to be served during grant period
signatures (both are required )
Signature of Executive Director
Signature of Board President
Date

Project/Proposal Summary

In general, the following narratives, which include Sections Two through Six, should not exceed ten pages in total. Responses should be typed, single-spaced, single-sided and use a 12-point type.

section two – organizational background

1)Brief summary of organization’s history and statement of organization’s mission

2)Brief description of current programs/projects and activities

3)Evidenceof organization’s overall effectiveness based on achievement of specific organizational or program goals

section three – statement of need

1)What is the problem, challenge or need that is unaddressed or unmet? Or what is the community benefit that this program or project will impart?

2)What is the research, statistic(s) or evidence that shows this needor benefit exists?


section four – program/project description & methodology

1)Description of program/project, including:

a)Summary description of overall program/project to be funded under this grant

b)Brief description of goals and objectives for program/project

c)Timetable for implementationand duration of program/project

d)Evidence of use of best practices (For example, is this program/project based on a program that has been shown to be effective in other settings? Is it based on national standards?). If the initiative is a pilot project and has not been done before, please list assumptions on why new approach will succeed.

2)Brief description of how grant funds will be used.

section five – program/project funding plans

1)List of other funders to whomthis current proposal has been and will be submitted. For each funder, indicate amount requested and status of request (e.g. “to be submitted,”“pending,”“funded,” or “declined”). If funded, specify amount of grant and date received.

2)Other anticipated funding for this current proposal including:

a)Earned revenue

b)In-kind support

c)Special events

d)Fundraisers, etc.

3)If this will be an ongoing program/project, describe plans and specific sources for future/long-term funding.


section six – evaluation and results

LIST 2-3 OUTCOMES FOR THIS PROPOSAL.

Program/Project Outcome(s)
The ultimate result of a program/ project /

Program/Project Measures

Measurable results of a program/ project / Benchmark (Quantitative Goal in numbers, percentages, task completion)
*Note: NO explanation of measure is needed.
Example 1:
To help 50 children receive dental care. / Children will improve their dental health / 50% of children participating schedule follow-up appointment


section seven – budget form

1)List all amounts in whole dollars.

2)Expenditures must be itemized for the total amount requested from the WRHF in Column 1.

3)All expenditures from the remaining other sources must be itemized in Column 2.

4)The total project expense in Column 3 must equal the total revenues.

REVENUES: / Project Budget
Western Reserve Health Foundation
TOTAL REVENUES / $
EXPENDITURES: / Column 1
Health Foundation / Column 2
All Other Sources / Column 3
Total Project Expense
Salaries and Wages
Fringe Benefits/Payroll Taxes
TOTAL PERSONNEL / $ / $ / $
OTHER EXPENSES:
Training
Travel
Consultants and Professional Fees
Rent & Utilities
Telephone
Supplies
Printing/ Postage
Equipment
Other:
Other:
Other:
Other:
Other:
Other:
TOTAL OTHER EXPENSES / $ / $ / $
TOTAL EXPENDITURES / $ / $ / $

section eight – required attachments

1)IRS letter of determination 501(c)(3). If not available or applicable, please explain. (If working with a Fiscal Agent, include their application information and a letter from them agreeing to act in that capacity for your organization.)

2)Most recent IRS Form 990. This should include all attachments, schedules and statements.

3)Current year’s budget and year-to-date expenditures.

4)Most recent financial statements, audited if available. This should include all auditor notes.

5)Complete list of the organization’s board members with their affiliations.

Submission of a full proposal must be emailed to

or mailed to

Community Foundation of the Mahoning Valley

201 E Commerce St

Youngstown, OH 44503

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