GEORGE TRIMBLE SPECIAL NEEDS CHARITABLE FUND

Grant Application

Application available online at .

Applications should be submittedonline.

Application due October 3, 2016

Organization Information

Name of Organization: ______

Website: ______

Mailing Address: ______

Number/Street

______

City State Zip

Telephone Number: (_____)______Fax Number: (_____)______

Executive Director/Top Executive Information

□ Mr. □ Mrs. □ Ms. □ Miss □ Dr. □ Rev. □ Gov.

Executive Director/Top Executive Name:

______First Middle Initial Last

Title: ______

Work Telephone Number: (_____)______Ext: _____

Alternate Telephone Number: (_____)______

Email Address: ______

Alternate Contact Information(if different than Executive Director/Top Executive)

□ Mr. □ Mrs. □ Ms. □ Miss □ Dr. □ Rev. □ Gov.

Alternate ContactName:

______First Middle Initial Last

Title: ______

Work Telephone Number: (_____)______Ext: _____

Alternate Telephone Number: (_____)______

Email Address: ______

Past Funding

Was the organization funded by the George Trimble Special Needs Charitable Fundin 2015?

□ Yes□ No

If yes, was a follow-up report submitted?

□ Yes□ No

If no, attachafollow-up report. (Access the electronical Follow-Up Form by contacting Brenda Sooter, )
(You must submit a follow-up report for consideration.)

Funding Request

Please provide a brief description of the organization and the population served(maximum 100 words).

List the organizations board members or principal parties.

Project/Program Title: ______

Type of grant requested. (If applicable, indicate more than one category.)

□ New Project/Program

□ Existing Project/Program

□ Capacity Building

□ Capital

□ General Operating Support

□ Other ______

Please indicate which category best reflects the purpose of the request. (If applicable, indicate more than one category.)

□ Arts & Culture

□ Community Preservation & Revitalization

□ Emergency/Disaster Needs

□ Health & Human Services

□ Science & Education

□ Other ______

In 100 words or less, please summarize the project/program.

Approximate number of Butler Countyarea residents to be served by the project/program: ______

How will the project/program directly impact the communities across Butler County(maximum 100 words)?

Please explain how the project/program will provide assistance to the welfare and safety of the citizens of Butler County, KS and the surrounding area by providing critical response to those 1) impacted by disasters, i.e. victims of fire, flood, or natural disasters; 2) for the promotion of public health, education, safety or other public cultural activities; or 3) for general assistance to the needy.(maximum 100 words).

Time period of project/program (November 1,2016 – September 1, 2017)(Grants may not be awarded retroactively for project/programs. Please see the highlighted time period and ensure that the project/program will not occur until after grants are estimated to be made. If your project/program has already happened or will happen prior to when grants will be made, it is not eligible.) : From: ______To: ______

Date when funds will be needed (no earlier than November 1, 2016): ______

Total project/program cost: $ ______

Total amount of funding requested from the George Trimble Special Needs Charitable Fund(not to exceed $3,000): $ ______

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? $ ______

Is there any pending funding sources for the project/program?

□ Yes□ No

If yes, please identify any pendingfunding source(s) including amount(s).

Is the project/program cost greater than the grant request?

□ Yes□ No

If yes, how will the remaining balance be raised(maximum 50 words)?

Is the grant request greater than the cost of the project/program?

□ Yes□ No

If yes, how would the additional funding, above the amount of the project/program, strengthen the project/program(maximum 50 words)?

Please describe how the organization will use the requested funds(maximum 100 words).

How was the need determined for the project/program(maximum 100 words)?

Is there any additional supplemental materials(brochure, letter of support, etc.) that you would like to include?

□ Yes□ No

If yes, please attach one additional supplemental material (brochure, letter of support, etc.). (Allowed file extensions: pdf., doc., docx., xls., jpg.)

Itemized and Prioritized Budget

George Trimble Special Needs Charitable Fund Grant Request: $ ______

Support and/or Revenue

Is there any committed support and/or revenue for the project/program?

□ Yes□ No

If yes, please list committed support and/or revenue source(s) and the amount(s) below.(If there is more committed support and/or revenue sources than lines you may combine them.)

Support/Revenue Source 1: ______

Support/Revenue Amount 1:$ ______

Support/Revenue Source 2: ______

Support/Revenue Amount 2:$ ______

Support/Revenue Source 3: ______

Support/Revenue Amount 3:$ ______

Support/Revenue Source 4: ______

Support/Revenue Amount 4:$ ______

Support/Revenue Source 5: ______

Support/Revenue Amount 5:$ ______

TOTAL Support and/or Revenue: $ ______

Expenses

Please list the project/program expense(s) and amount(s) below(priority first).(If there is more expenses than lines you may combine them.)

Expense 1: ______

Expense Amount 1: $ ______

Expense 2: ______

Expense Amount 2: $ ______

Expense 3: ______

Expense Amount 3: $ ______

Expense 4: ______

Expense Amount 4: $ ______

Expense 5: ______

Expense Amount 5: $ ______

Expense 6: ______

Expense Amount 6: $ ______

Expense 7: ______

Expense Amount 7: $ ______

Expense 8: ______

Expense Amount 8: $ ______

Expense 9: ______

Expense Amount 9: $ ______

Expense 10: ______

Expense Amount 10: $ ______

TOTAL Expenses: $ ______

Budget Difference (TOTAL Expenses minus TOTAL Support and/or Revenue): $ ______

Is there any additional budget informationthat you would like to include?

□ Yes□ No

If yes, please attach additional budget information.(Allowed file extensions: pdf., doc., docx., xls., jpg.)

Declaration and Compliance

Doestheorganization possess a 501(c)(3) status under the Internal Revenue Service code?

□ Yes□ No

If yes, please attach proof of 501(c)(3) status.(Allowed file extensions: pdf., doc., docx., xls., jpg.)

If no, is the organization exempt under statute(i.e., educational institution, church, city, or county)?

□ Yes□ No

If yes, please identify the organization exempt under statute.

Name of Organization: ______

Contact Person: ______

Mailing Address: ______

Number/Street

______

City State Zip

Telephone Number: (_____)______Ext: _____

Email Address: ______

Please attach proof of exemption under statute. (Allowed file extensions: pdf., doc., docx., xls., jpg.)

If no, please identify the eligible organization that will serve as the project/programs fiscal agent.(Organization must possess a 501(c)(3) status under the Internal Revenue Service code or be exempt under statute.)

Name of Organization: ______

Contact Person: ______

Mailing Address: ______

Number/Street

______

City State Zip

Telephone Number: (_____)______Ext: _____

Email Address: ______

Please attach proof of project/programs fiscal agent’s 501(c)(3)status or exemption under statute. (Allowed file extensions: pdf., doc., docx., xls., jpg.)

Employer Identification Number (EIN): ______

We give permission to use our organization’s 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 George Trimble Special Needs Charitable Fund managed by El Dorado Community Foundation,an affiliate of Central Kansas Community Foundation, for the purposes described herein shall be restricted as stated herein.

______

Signature of Representative Requesting Grant Date

The George Trimble Special Needs Charitable Fund is managed by El Dorado Community Foundation, an affiliate of Central Kansas Community Foundation, a IRC § 501(c)(3) charitable corporation organized under the nonprofit corporation laws of the state of Kansas, with its principal office located at 301 North Main, Newton, Kansas, 67114.If you have questions or need further information, please contact Angie Tatro, CKCF Executive Director, at or 316.283.5474. Additional information posted at .

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