Rotary Club of Smyrna
Grant Request
Grant Checklist
□ Completed application (no partially completed applications will be accepted)
□ Current list of agency’s Board of Directors
□ Letter of IRS determination of Tax-Exempt Status 501(c)(3)
□ Agency’s latest audit and management letter or year-end balance sheet and
statement of activity, if agency is not audited
□ Most recent Financial Statement
□ List of partner organizations
□ Certificate of insurance indicating general liability coverage of all volunteers,
if applicable
¨ Completed grant requests should be submitted to the current Rotary president
¨ Absolute deadline for grant submittal is August 1st of each year.
The checklist must be complete and contain current information. Incomplete applications
will not be considered.
We invite your application and look forward to working with you. Please note that submittal of this grant application does not guarantee funding and that funding requests must be submitted annually for consideration. If you need more information, have questions or would like to obtain a Word form of this document, please visit our web site at
www.rotaryofsmyrna.org
______
Organization/Agency Name
Date of Application
______
Primary Contact Person Telephone E-Mail Address
______
Street Address/Post Office Box City State/Zip
______
Home Phone Work Phone Mobile Phone
______
Internet site address Fax Number
Secondary Contact Person Telephone E-Mail Address
______
Street Address/Post Office Box City State/Zip
______
Home Phone Work Phone Mobile Phone
Have you previously received funds from the Rotary Club of Smyrna? □Yes □No
If yes, please list and include disclosure of those grant funds received:
Date Amount Date Amount
______
______
______
Is your organization/agency exempt from payment of income tax? □Yes □No
If yes, a copy of form 501(c)(3) from Internal Revenue Service AND either a Form 990 or a Financial Statement must be attached.
Application Deadline: The Annual deadline for applications is August 1st of each year. Requests will be prioritized based on evaluation and need during the month of September and October with funds distribution to successful applicants during the months of November through March. Special needs cases will be considered on a case by case basis.
Primary funding agency of applicant - List source(s) from which you already receive revenue.
______
______
______
Is your organization/agency currently located in the Middle TN area? □Yes □No
When will these funds be needed? What is the timeline for this project? ______
Sustainability – How do you plan to keep this project functioning for the next five years?
Please briefly summarize your past and present affiliation, if any, with the Rotary Club of Smyrna, including the names of any member of your organization/agency who is also affiliated or a member of the Rotary Club of Smyrna.
______
______
Describe volunteer opportunities that Rotarians may be able to contribute to the project:
How will you publicize Rotary Club of Smyrna involvement with your project and grant funding?
State purpose of request. List specifically how funding will be utilized with full description of your need; how this need originated; how it will benefit your clients/program; and how will you determine whether these funds have achieved its goals. (Attach additional sheets if necessary.)
Which six Areas of Rotary Focus does your project meet? Also see www.Rotary.org for more information
1) Basic Education and Literacy
2) Water and Sanitation
3) Mother and Child Health
4) Prevention and Treatment of Disease
5) Prevention and Resolution of Conflicts and the Promotion of Peace
6) Economic and Community Development (Includes shelter / housing)
*Grant recipients must provide a written report to the Smyrna Rotary Club no later than June 1st of each year describing the outcome of the project and how the Smyrna Rotary Club contributed to the goals of the project. This report must be received (by June 1st of each year) in order to be considered in the next grant application period.
Estimated total amount needed for project: $______
Totals from other funding sources: $______
Total requested from Rotary Club of Smyrna $______
The information contained in this statement is for the purpose of obtaining funding from the Rotary Club of Smyrna on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding to grant funding, and each undersigned represents and warrants that the information provided is true and complete and the Rotary Club of Smyrna may consider this statement as continuing to be true and correct until a written notice of change is provided. Rotary Club of Smyrna is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.
Signature of Representative ______
Title of Representative ______
Date ______