an affiliate of Central Kansas Community Foundation
Butler County Community
Grant Application
Application available online at .
Applications should be submittedonline.
Application due April 13, 2015
Funding requests will be reviewed by the Butler County CommunityGrant Selection Committee’s. Applicants will be notified in May of their award status. Recipients will be announced at the Central Kansas Community Foundation-Butler County Awards Banquet in El Dorado, Kansas on June 6, 2015.
Organization Name: ______
Organization Website: ______
Mailing Address: ______
Number/Street
______
City State Zip
Telephone: (_____)______Fax: (_____)______
Executive Director/Top Executive: ______
Title: ______
Telephone: (_____)______Ext: _____ Alternate Telephone: (_____)______
Email Address: ______
Project/Program Director (if different than Executive Director/Top Executive):
______
Title: ______
Telephone: (_____)______Ext: _____ Alternate Telephone: (_____)______
Email Address: ______
Was your organization funded in 2014 by the Greater Butler County Community Impact Grant?
□ Yes□ No
If yes, was afollow-up report submitted?
□ Yes□ No
If no, a follow-up report must be submitted for consideration.
□ Follow-up report is included with the application.
Please provide a brief description of your agency and the population served.
Project/Program Title: ______
Type of grant requested. (You can indicate more than one category if applicable.)
□ Capacity Building
□ Capital
□ General Operating Support
□ New Project/Program
□ Existing Project/Program
□ Other ______
Please indicate which category best reflects the purpose of the request. (You can indicate more than one category if applicable.)
□ Arts & Culture
□ Science & Education
□ Community Preservation & Revitalization
□ Health & Human Services
□ Emergency/Disaster Needs
□ Animal Welfare
□ Other ______
In 100 words or less, please summarize the project/program.
Approximate number of people to be served by the project/program: ______
Will the project/program directly impact the community or residents of Douglass, Kansas?
□ Yes□ No
If yes, please explain.
Will the project/program directly impact the community or residents of El Dorado, Kansas?
□ Yes□ No
If yes, please explain.
Time period of project/program (June 6, 2015 – March 1, 2016): From: ______To: ______
Date when funds will be needed (No earlier than June 6, 2015): ______
Total amount of funding requested from the Butler County Community Grant (grant awards will be between $150 to $500 for all requests, except health and human service grant requests relating to children’s health and well-being may be between $150 to $1,500): $ ______
Total grant requests frequently exceed the amount of available funding. Is there aminimum grant amount acceptable for the project/program to proceed?
□ Yes□ No
If yes, what is the minimum grant amount acceptable for the project/program to proceed? $ ______
Do you have any pending funding sources for the project/program?
□ Yes□ No
If yes, please identify anypending source(s) including amount(s).
Is the project/program cost greater than the grant request?
□ Yes□ No
If yes, how do you plan to raise the remaining balance?
Is your grant request greater than the cost of the project/program?
□ Yes□ No
If additional funding, above the amount of the project/program, was made available to your organization, how would the additional funds strengthen the project/program?
Please describe how your agency will use the requested funds.
How will the project/program directly impact the people your agency serves?
How did you determine the need for the project/program?
How will you evaluate the success of the project/program?
What will result if the request is not funded by the Butler County Community Grant?
Is there an additional supplemental material (brochure, letter of support, etc.) that you would like to include with the application?
□ Yes□ No
If yes, please attachone additionalsupplemental material (brochure, letter of support, etc.) to the application.
Please fill out the “Itemized and Prioritized Budget” within the online grant application for the project/program you are requesting funds for.
□ Itemized and prioritized budget for the project/program is completed within the online grant application.
Do you have an additional file to upload with the proposed project/program budget?
□ Yes□ No
If yes, please attachone additionalsupplemental material for the proposed project/program budgetto the application.
□ Organization is a 501(c)(3).
□ Proof of 501(c)(3) status is included with the application.
□Organization is not a 501(c)(3).
Is your organization a public agency/unit of government? (i.e., educational institution, church, city, or county) □ Yes □ No
If yes, please identify the public agency/unit of government.
Name of Public Agency/Unit of Government: ______
Contact Person: ______
Mailing Address: ______
Number/Street
______
City State Zip
Telephone: (_____)______Ext: _____
Email: ______
If no, please identify the qualified organization that will serve as the project/programs fiscal sponsor.
Name of Organization: ______
Contact Person: ______
Mailing Address: ______
Number/Street
______
City State Zip
Telephone: (_____)______Ext: _____
Email: ______
□ Proof of project/programs fiscal sponsor’s 501(c)(3) status is included with this application.
Employer Identification Number (EIN): ______
We give permission to use our organizations name and project/program in publicity.
□ Yes□ No
***********************************
I certify, to the best of my knowledge, that all information included in this application is correct. The tax exempt status of this organization is current. If grant is received through the Central Kansas Community Foundation-Butler County, an affiliate of Central Kansas Community Foundation, for the purposes described herein shall be restricted as stated herein.
______
Signature of Representative Requesting Grant Date
Central Kansas Community Foundation – Butler County, an affiliate of Central Kansas Community Foundation,manages the Butler County Community Grant Funds. If you have questions or need further information, please contact Chancy Gerbitz at or 316.283.5474. Additional information posted at .
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