VILLAGE OF DOWNERS GROVE

COMMUNITY GRANTS PROGRAM

Application Form

This application form must be submitted in its entirety to: Village of Downers Grove, Susan Brassfield, Grants Coordinator, 801 Burlington Avenue, Downers Grove, Illinois 60515 or by email at , by

October 30, 2009, for your application to be considered. Please type or print clearly using black ink.

Organization Name:
Address:
City: / State: / Zip:
Director:
Contact Person & Title:

(for this application/project)

Area Code & Phone: / Fax:
Web Site: / E-Mail:
Date Submitted: / Amount Requested from Community Grants Program: $
Program/Project Name:
Total annual ORGANIZATION budget: $
Total annual PROJECT budget: (if applicable) $
Date/s of event or activity:

(Specify month, day, and year)

Does your organization have its tax-exempt 501(c)(3) status? Yes No FEIN #:

Supporting Materials (Please submit one copy with your application)

Verification of your organization’s not-for-profit status, which is defined in the Village ordinance as an organization registered as not-for-profit with the Illinois Secretary of State, or an entity affiliated therewith, or an organization qualified as tax exempt pursuant to Internal Revenue Code, or an entity affiliated therewith, but shall not include any unit of government or taxing body.

A copy of your organization’s annual budget.

1. History of Applicant Organization (Provide a history of the organization, its mission statement and a list of the Board of Directors.)

2. Project Summary (Clearly and concisely summarize the project for which funds are being requested and how this project meets the mission of the Community Grants Program.)

3. Is this a new project or event for Downers Grove? Yes No

4. Will this project attract nonresidents? Yes No

5. Value to the Community (Indicate how this project will be of value to the Village of Downers Grove.)

6. Overall Goals and/or Objectives (Describe how grant funds will meet the project objective.)

7. Marketing/Advertising (Describe details of your project, including marketing and advertising objectives.)

8. Population Served (Describe the population[s] this project or organization will serve through this grant

request.)

9. Project Evaluation (Describe in measurable terms (i.e., audience surveys) how the project will be evaluated including the methods that will be used in evaluating the project’s success.)

10. Current Funding (Identify other project funding sources (e.g.) government/corporate/foundation/individual in the form of grants/gifts/sponsorships.)

11. Future Funding (Describe future funding plans of this project. Is this project a one-time event or does the applicant anticipate continuation of the project on an annual basis?)

Budget for Proposed Project (Attach a total line-item budget specifying anticipated income, expenses, each funding source, and in-kind contributions for the project. Also, specify which aspects of the budget will utilize grant funds.)

Projected Program/Project Budget / Budget Items Requested from Community Grants Program
Expenses:
Total Projected Expenses:
Revenue:
Government Grants
Corporate/Foundation Grants
In-kind Support
Individual Donors
Other:
Total Projected Revenue:

LIABILITY

Neither acceptance of this grant application nor awarding of funds shall create any liability or responsibility on the part of the Village of Downers Grove or the Community Grants Commission, their officers, agents and employees, regarding the conduct of applicant's event or injuries arising therefrom. Applicant shall be solely responsible to all contractors, suppliers, laborers, material providers and other persons providing goods and services to the applicant. In no way shall the Village of Downers Grove or the Community Grants Commission be considered or deemed to be a cosponsor of the event unless expressly approved by the Village Council of Downers Grove. Applicant agrees to indemnify and hold harmless the Village of Downers Grove and the Community Grants Commission, their officers, agents and employees, from any and all liability, claims, suit and damages, whatsoever, arising out of the acceptance of this application form, the granting of funds or the conduct of any activity paid for in whole or in part by said funds.

STATEMENT OF ASSURANCES

The applicant hereby agrees that:

1. The activities and services for which assistance is sought will be administered by the applicant.

2. The figures, facts and representations in this application including all attachments, are true and correct to the

best of the applicant’s knowledge and belief.

3. The filing of this application with the Community Grants Commission of the Village of Downers Grove has been authorized by the governing board of the applicant.

4. The applicant will expend funds received as a result of this application solely for the projects and programs described above.

5. The applicant does not and will not engage in any practices or procedures which discriminate on the basis of race, color, sex, national origin, age or physical or mental handicap or disability, in violation of federal or state law.

6. Should this grant request be approved, applicant agrees to submit to the Community Grants Commission a narrative and quantitative report (using a format provided by the Commission) within 45 days after the stated ending date of the project.

7. All requests for reimbursement shall be submitted within forty-five (45) days after the event or activity is held; however, no reimbursement request shall be submitted after January 30, 2011. By December 1, 2010, the Grants Coordinator requires an estimate of expenses that will be submitted after December 31, 2010.

The applicant understands that issuance of grant funds will be made on a reimbursement basis and will be processed within 60 days of satisfactory documentation of payment.

Date / Signature of Authorizing Official
The electronic submittal of an application will be considered a final document and the authorized signature or printed name is held liable for all information herein. /
Printed Name and Title of Authorizing Official
For staff use only:
Date Application Received: / Date of CGC :
CGC Action: Approved Amount: / Denied
Staff Signature: / Date: