Grant Application - Kilian Schmitt Foundation

Executive Summary

Organization Name*

Project/Activity Name*

One sentence summary of the project/activity*

Why is there a community need?*

Who and how many people (target population, age, gender, ethnicity, other)*

What services are provided?*

When (timeframe)*

Where (location of the work)*

What do you hope to accomplish (outcomes)?*

How does this request meet this funder's priorities?*

Total cost of this effort:*

Amount requested from this funder:*

Signature of CEO*

By typing my name below, I confirm that I am an authorized by my organization to submit this application, and that the information provided is true and correct to the best of my knowledge.

Signature of a board representative (chair or president)*

By typing my name below, I confirm that I am an authorized by my organization to submit this application, and that the information provided is true and correct to the best of my knowledge.

Financial summary of your organization's most recently completed fiscal year (PDF)*

including the original budget and the actual revenue and expenses for that year.

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 3.

If you are a 501(c)(3) organization, a copy of the IRS determination letter (PDF)

advising that your organization is exempt from taxes under Section 501(c)(3) of the IRS code, and that the organization is not a private foundation as defined in Section 509(a).

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 1.

List of the organization's Board of Directors*

with their affiliations.

Organization Information

Name of Organization*

Organization Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax

Your Email*

Enter Email Confirm Email

Name of Chief Executive*

First Last

Title*

9-digit Federal Employer ID:*

Year incorporated:*

Information for This Request

Name of this program or project:*

Name of contact person:*

First Last

Phone*

Type:*

Capital

Endowment

Program/Project

General Support

Other (describe)

If "Other" please explain:

Date funds needed by:*

Date by which funds will be spent:*

Rochester Area Logic Model

Inputs*

($'s, staff, volunteers, materials and other resources requitred) Quantify inputs whereer possible (e.g. "2.5 FTE social workers, 270 volunteer hours")

Activities*

(What the program does with the inputs to achieve its outcomes) Activities should be quantified (e.g. "2 support groups/10 moms ea./2hrs/wk for 4 mos.")

Projected Outcomes - Short Term*

(Effects on knowledge, attitudes, skills, behavior, condition or status during or after the program/project) Place a "*" next to those to be measured.

Projected Outcomes - Long Term*

(Effects on knowledge, attitudes, skills, behavior, condition or status during or after the program/project) Place a "*" next to those to be measured.

Rationale

Need/demand*

present in bulleted format, and where possible, include local statistics, community priorities, etc. 1. Summarize the need for your planned work. 2. Summarize customer demand for this work.

Accepted file types: jpg, jpeg, png, pdf, docx, xls, Max. file size: 2 MB.

For each outcome you will track, as identified in your logic model, indicate how you will know if you succeed in achieving it, using the following format:

Outcomes*

Indicators/Measures*

What will you measure to know if you reach your outcomes?

Targets/Performance*

Standards/Projected levels of success. What ill tell you that you have achieved your outcomes?

When will these targets be achieved?*

Agreement*

by submitting this application, you understand that this does not guarantee funding from this organization.

I agree to the terms of service