Grant Application Duluth Superior Area Community Foundation Grant Application

Duluth Superior Area Community Foundation Grant Application
Duluth Superior Area Community Foundation
Grant Application
Zeitgeist Arts Building 222 East Superior St, Ste 302 Duluth, MN 55802
This application is based on the Minnesota Common Grant Application, but does contain some modifications
for an online format.
INSTRUCTIONS
Step 1: Complete the online application form.
Please complete all sections of the application and limit your answers to the space provided. After completing
the application, please save the document using the ‘save as’ feature and include your organization’s name in the
document name. This will be your copy of the application. Move to Step 2.
This form is designed with Adobe Reader. You perhaps can open and type into it with your web browser,
HOWEVER, the save function may not work correctly if you do so. It is therefore important to use ADOBE
READER to create a document which is fill-able, save-able and return-able.
Application Sections
•Grant Application Information Summary
•Organizational Information
•Proposal Information
•Evaluation Information
•Organizational Budget
•Organization Funders
•Project Budget
•Project Funders
•List of Board of Directors
•Self Certification
Step 2: Submit Attachments
The following items must be sent for the grant application to be considered complete. If possible, please scan
the original documents and send as an attachment with the application to
grantsinfo@dsacommunityfoundation.com.
•Cover Letter (optional) If desired, please include the cover letter with the completed application.
•Audited financial statement If current year audit is not available, send the most recent audit you have, and
the unaudited year end financial statement of income and expenses for the most recently completed fiscal
year. Send the audit when it is available. An audit is highly preferred. If your organization isn't audited, an
IRS Form 990 for the most recently completed fiscal year is required.
•Copy of most recent IRS Determination Letter indicating 501(c)(3) status.
Step 3: If applying using a Fiscal Agent:
You will need a Fiscal Agent in order to apply for a grant from the Community Foundation, if your
organization has not yet secured a 501(c)(3) determination letter from the Internal Revenue Service. The
following information is needed from your Fiscal Agent: If possible, please scan the original documents and
send as an attachment to grantsinfo@dsacommunityfoundation.com
•Acknowledgment in writing from the Fiscal Agent to accept funds on your organization's behalf for your project.
•A copy of your Fiscal Agent's 501(c)(3) IRS ruling.
•A list of your Fiscal Agent's Board of Directors.
•A copy of your Fiscal Agent's most recent independent audit.
Questions or concerns? Please contact us at 218.726.0232 or grantsinfo@dsacommunityfoundation.com
Duluth Superior
Community
Foundation
Grant
Application
One finalArea
reminder:
please be sure to
use Adobe Reader
to complete
this form!
Download the form to your desktop; open Reader; go to File / Open in the top dropdown menu; select this form; click return
GRANT APPLICATION INFORMATION SUMMARY
Name of Organization
Legal name, if different
Address
Line 1
Address
Line 2
City
State
Zip
Website
Employer Identification Number (EIN)
Phone
Fax
Name of top paid staff or Board Chair
Title
Phone
Email
Contact person for this application
Phone
Title
Email
Is your organization an IRS 501(c)(3) not for profit, public entity or unit of government?
Yes
No
If no, see page one for details on using fiscal agents and list the name and address of fiscal agent:
Ficsal Agent Name
Address
Line 1
Address
Line 2
City
State
Ficsal Agent's EIN
Zip
Proposal Information
Project/Program Name
Geographic Area
Served
Funds are being requested for (select one)
General Operating
Capital
Support
Population
Served
Start Up
Costs
Technical
Assistance
Other (please explain)
Project Dates
Start (MM/DD/YY)
End (MM/DD/YY)
Fiscal Year End
Budget
Community Foundation Fund Applying To
Amount
Requested
Total Project
Budget
Can we share this application for funding with a Donor Advisor?
Total Annual Organization Budget
for the year requesting funds
Yes
No
Project/Program
Support
ORGANIZATIONAL
Duluth
SuperiorINFORMATION
Area Community Foundation Grant Application
Please provide a brief summary of the organization history, mission/goals and current programs or activities,
including any service statistics and strengths or accomplishments.
Please indicate the structure of your organization, number of board members, full-time paid staff, part-time paid staff and
volunteers.
Duluth
Community
Foundation
Grant
What is yourSuperior
organization’sArea
relationship
with other organizations
working with
similar Application
missions? What is your
organization’s role relative to these organizations?
PROJECT/PROGRAM INFORMATION
Please provide a detailed description of the proposed project and the specific activities for which you are seeking funding.
Duluth Superior Area
Community
Foundation
PROJECT/PROGRAM
INFORMATION
(continued)
Grant Application
Please describe the opportunity, challenges, issues/need within the community that your proposal addresses.
Describe your overall goal(s) regarding the situation described above; what are the objectives or ways in which you will
meet those goal(s)?
Duluth
Area
Community
Grant
How will theSuperior
proposed activities
benefit
the community,Foundation
being as clear as you
can aboutApplication
the impact you expect to have?
Briefly describe how this focus was determined and who was involved in that decision-making process.
Who will carry out the activities in the proposed project? What is the timeframe in which this will take place?
Duluth
Superior
Community Foundation Grant Application
How does the
project fit theArea
fund's guidelines/strategy?
What are the long-term funding strategies (if applicable) for sustaining this effort?
EVALUATION
INFORMATION
Duluth Superior
Area Community
Foundation Grant Application
Describe your criteria for the project's success, how you will measure the changes, and use the evaluation results?
How will you measure the effectiveness of the project?
Who
will evaluate
the effectiveness
the project?
Duluth
Superior
AreaofCommunity
Foundation Grant Application
ADDITIONAL INFORMATION
Please use this space to provide additional information or continue any answers that do not fit in the spaces provided above.
Duluth Superior Area Community Foundation Grant Application
ORGANIZATIONAL BUDGET
Provide budget information for the fiscal year for which funds are to be used.
Please check this box if you would prefer to submit an organizational budget that contains this information in a
different format. Send organizational budget to grantsinfo@dsacommunityfoundation.com.
SUPPORT INCOME
Source
Amount
Government grants
Foundations
Corporations
United Way/Other Campaigns
Individual Contributions
Fundraising Events & Products
Membership Income
In-kind Support
Investment Income
REVENUE INCOME
Government Contracts
Source
Amount
Item
Amount
Earned Income
Other (please specify)
Total Income
EXPENSES
Salaries & Wages
Insurance/benefits/other taxes
Consultants & Professional Fees
Travel
Equipment
Supplies
Printing & Copying
Telephone & Fax
Postage & Delivery
Rent & Utilities
In-kind Expenses
Depreciation
Other (please specify)
Total Expenses
Difference (Income less Expense)
Duluth
Superior Area Community Foundation Grant Application
ORGANIZATION FUNDERS (government, foundation, corporate)
Prior Year
Funder's Name
Amount
Current Year
Funder's Name
*TBA = To Be Approached
Secured / Pending / TBA*
Amount
Duluth
Superior Area Community Foundation Grant Application
PROJECT BUDGET
Please check this box if you would prefer to submit a project budget that contains this information in a different
format. Send project budget to grantsinfo@dsacommunityfoundation.com.
SUPPORT INCOME
Source
Secured/Pending/TBA* Amount
Government grants
Foundations
Corporations
United Way/Other
Individual Contributions
Fundraising Events/Products
Membership Income
In-kind Support
Investment Income
REVENUE INCOME
Government Contracts
Earned Income
Other (please specify)
Total Project Income
EXPENSES
Salaries & Wages
(breakdown by individual
position, indicate full- or
part-time.)
Item
% FTE
Subtotal
Insurance/benefits/other taxes
Consultants & Professional Fees
Travel
Equipment
Supplies
Printing & Copying
Telephone & Fax
Postage & Delivery
Rent & Utilities
In-kind Expenses
Depreciation
Other (please specify)
Total Project Expenses
Difference (Income less Expense)
Amount
Duluth Superior Area Community Foundation Grant Application
LIST OF PROJECT FUNDERS
Prior Year
Funder's Name
Amount
Current Year
Funder's Name
*TBA = To Be Approached
Secured / Pending / TBA*
Amount
DuluthOFSuperior
Area
BOARD
DIRECTORS
Community Foundation Grant Application
Please check this box if you would prefer to submit your board of directors list in a different format.
Employer/Former
Employer (affiliation)
Job Title
Name
Board Title
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Duluth Superior Area Community Foundation Grant Application
SELF-CERTIFICATION CHECKLIST
All materials must be received by 5:00pm on the application deadline. Please indicate how the materials will be submitted.
Online Form
Emailed
Mailed
On File
N/A
1. Cover Letter (optional)
2. Grant Application Information
3. Organizational Information
4. Proposal Information
5. Evaluation Information
6. Organization Budget
7. Organization Funders
8. Project Budget
9. Project Funders
10. List of Board of Directors
11. Audited financial statement or IRS Form 990
12. Copy of federal IRS Determination Letter
indicating 501(c) (3) tax exempt status
If applying using a fiscal agent:
Emailed
Mailed
1. A written agreement from the Fiscal Agent to accept
funds on your organization’s behalf for your project.
2. A copy of your Fiscal Agent’s 501(c)(3) IRS ruling
3. A list of your Fiscal Agent’s Board of Directors
4. A copy of your Fiscal Agent’s most recent independent audit
CERTIFICATION STATEMENT
By checking this box, I certify that all the information in this application is true to the best of my knowledge. In
addition, I certify that I will submit a complete application, fulfilling all of the items on the self-certification checklist
on the first page of the application. I also acknowledge that the organization’s top paid staff member or Board Chair
is aware of the submission of this grant application to the Duluth Superior Area Community Foundation.
Name
Title