/ Rotary Club Report Form
Rotary District Grant - District 5650
2013-2014 Rotary Year Grants

District Grant #DG1410668

Form Submission Instructions:

- - Form at -> Grants Page

- - Complete form “on screen”- - Send by email to:

- - Print and SignDistrict Grants sub-Committee Chair:

- - Scan to create electronic copyNicolette “Nicki” Klein - .

Rotary Club (Lead Rotary Club for multi-club projects):

Project Title (BRIEF - describe below):

This is a Progress Report - required for all projects not completed by December 31, 2013.

This is a Final Report – which is to be filed within 30 days of the completed project, no later than March 31, 2014.

  1. Project Description - briefly describe the project.
    What was done?
    When and where did project activities take place?
    Who were the beneficiaries of the project?
  1. Rotarian involvement – Important- show Rotarian involvement besides providing grant funds.
    How many Rotarians participated in the project as volunteers?
    What the Rotarian volunteers did / provided:
  1. Non-Rotariansthat benefit from this project (who, how many?)
  1. Community impact - what is the expected long-term community impact of the project?
  1. Public Relations/Media Coverage:

Required – the Rotary Wheel has been placed – describe:

Print Media – describe

Broadcast Media (radio, TV) – describe

Internet – Websites, Social Media – describe

  1. Role of Cooperating Organizations (if any):

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District Grant 2013-14 Report FormFront – Page 1

  1. Financial Report

A separate bank account was established for managing all project funds (established by the Lead Club on multi-club projects)

All project funds – the District Grant Check as well as the funds from all participating clubs (including the Lead Club on multi-club projects) were deposited to the bank account established in the item above

Copies of bank statements (income) are scanned and attached to this report; for multi-club projects, copies of the checks received from all clubs, including the Lead Club and deposit tickets detailing the deposits are to be provided

Copies of bank statements, including check images, showing all checks paid out on the project (expenses) are scanned and attached to this report

Actual expenditures are to be listed below and must be supported by receipts; it is not required that the receipts be scanned and attached but must be retained by the club and be availablefor 3 years in case of an audit of the project/funding

Income (for multi-club projects, list each club and the amount provided)Amount

1. District Grant funds received from the District
2. Rotary Club funds (minimum to earn match required for each club)
Rotary Club
Rotary Club
Rotary Club
Rotary Club
Rotary Club
Rotary Club
3. Other funding (specify)
Total Project Income

Actual Expenditures (please be specific and add pages as needed)

1.
2.
3.
4.
5.
6.
7.
Total Project Expenditures
  1. By signing this report, I confirm that, to the best of my knowledge, these District Grant funds were spent only for eligible items in accordance with The Rotary Foundation and District-approved guidelines, that all of the information contained herein is true and accurate, and that the requirements outlined in the memorandum of understanding were met. For multi-club projects, this form is to be signed by the Lead Club.

Certifying Signature Date:

Printed Name of SignerRotary Club Name

District Grant 2013-14 Report FormBack– Page 2