Roseville Community Fund

Roseville Community Fund

Grant Application

Please complete all sections of the following grant application. Adopted: 09/11/2003

A. General Information

Date:

Name of organization: _____

Address: _____

Responsible person:

Name Title Phone

Email:

Contact person:

Name Title Phone

IRS status:  501(c)(3) (Please attach letter from the IRS.)  Other: _____

Do you have an application for non-profit status pending with the IRS?  Yes  No

Has the IRS ever declined to grant a 501(c)(3) status to your organization?  Yes  No

B. Grant

1. a. Briefly describe the purpose of the project or program, the need it addresses, the goal and how it benefits the community of Roseville.

b. How will you measure the success of your project?

2. Give the names, experience, and describe briefly the role of the individuals who will

supervise or implement the project.

b.  Geographic area served:

Approximate Number of people served:

Circle all that apply: male female minority youth elderly

4. a. Summarize your budget request:

Organization’s total annual budget: $

Total project budget: $

Roseville Community Fund amount requested: $

Scheduled implementation dates:

b.  Show itemized project budget (please attach)

5. List other funding sources approached, amounts requested, status of the request and any plans for future funding sources.

a.

b.

c.

d.

6.  Have you submitted a prior grant request for funds from the Roseville Community Fund.

 No  Yes

If yes, was it:  approved:  declined Date:

Comments:

7. Please describe any relationship or interest with members of the Roseville Community Fund which might be considered in conflict of interest if not declared.

C. Responsible Governing Body Approval: (if applicable)

Signature of Board Chair (if applicable): Date:

Signature of Exec. Director/Project Manager: Date:

The Roseville Community Fund will invite each applicant to have a representative present at the meeting.

For additional information or submission of applications please contact:

Roseville Community Fund

of the North Suburban Community Foundation

2233 North Hamline Ave., Suite 511

Roseville, MN 55113

651/633-3623

Roseville Community Fund

Mission:

To administer charitable funds to enhance the physical, emotional, cultural and intellectual life of the Roseville Area community.

Background:

The Roseville Community Fund was established by an agreement between the City of Roseville and the North Suburban Community Foundation, a Minnesota non-profit corporation, in 1991. The Roseville Community Fund distributes a portion of profits from lawful gambling on behalf of the City Council.

The Fund welcomes requests from local non-profit athletic and non-athletic organizations, from fraternal and service organizations, from churches and schools, for projects which will primarily benefit the community of Roseville and closely related north suburban communities.

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Consideration for Grant Applicants

Before you complete your application form, be certain:

·  That you provide documentation of your IRS status as a non-profit 501(c)(3) or as a public agency or unit of government.

·  That your project is carefully thought out, with a plan of action, budget for the project, and you have the personnel to implement it.

·  That you have a realistic timetable for implementing the project.

·  That a qualified representative will appear before the Roseville Community Fund Advisory Board to discuss your project and answer additional questions Board members may ask.

·  That your application is completed and submitted within the prescribed time frame.

·  That you are prepared to provide information to the Board within 12 months of receiving the funds as to the completion, results and success of the project.

·  That you are serving the Roseville area according to our mission statement.

RCF/ph Grant Application / page 1