| 1. |
Legal
Name of Organization |
| 2. |
Address,
City, State |
| 3. |
Telephone,
Fax, Email address, Web address (if available) |
| 4. |
Name
and title of Contact Person |
| 5. |
Name
and signature of Executive Director |
| 6. |
Name
of Board President |
| 7. |
Federal
ID number |
| 8. |
IRS
501c3 nonprofit? Please circle: YES
NO |
| |
If
yes, please attach copy of designation letter
from the IRS. |
| 9. |
Amount
requested: $_____________ |
| 10. |
From
which fund is support being requested? |
| |
|
____ Capacity
Development Fund |
| |
|
____ Strategic
Leverage Fund |
| 11. |
State
the organization’s mission (approximately
two sentences) |
| 12. |
Summarize
the proposal and how it will increase the
organization’s capacity (no than four
sentences). |
| 13. |
Community
services currently offered by your organization.
|
| 14. |
Proposal’s
impact on specific programs offered by your
organization. |
| 15. |
Proposal’s
target population, constituents, and geographic
communities |
| 16. |
Proposal’s
impact on people served and on the community
in general. |
| 17. |
Total
number of board members. |
| 18. |
Total
number of employees: full time____ part time____
volunteer____ |
| 19. |
Total
annual organizational budget: $_________________
|
| 20. |
Dates
of fiscal year: |
| 21. |
Time
period this grant will cover: __________/__________
to __________/_________ |
| |
|
| ORGANIZATIONAL
INFORMATION (25%) |
| 1. |
Provide
a brief summary of your organization’s |
| 2. |
Describe
your current community outreach programs,
activities, and accomplishments, with an emphasis
on the past year. |
| 3. |
Outline
your organization’s primary sources
of support--including financial, in-kind,
and volunteer resources--over the past three
years. |
| 4. |
Explain
what makes your organization unique or distinct. |
| |
|
| PURPOSE
OF GRANT (40%) |
| 1. |
State
the type of support you are requesting (project,
program, or operating) and the amount being
requested. |
| 2. |
Describe
the situation--opportunity, problem, issue,
need, and the community--that your proposal
addresses, and how that was determined. |
| 3. |
Define
the overall goal(s) of this grant request. |
| 4. |
List
the objectives that will enable you to achieve
your goals. |
| 5. |
Explain
how you will accomplish these objectives including: |
| |
 |
Specific
activities planned |
| |
|
Timeframes
for activities |
| |
|
Target population
and number of people served |
| 6. |
Describe
how these activities will impact the community
you serve. |
| 7. |
Explain
how and when you will measure the results.
|
| 8. |
Summarize
the major goals of your organization’s
strategic plan for the next three years. |
| 9. |
If
applying for a project or program grant, provide
a detailed resource development plans that
explains: |
| |
|
How this
grant will leverage additional resources |
| |
|
How additional
support will result in an expansion of services
OR |
| |
|
How additional
support will result in an improvement of services |
| |
|
How this
resource development plan fits into your organization’s
strategic plan |
| 10. |
If
applying for an operations grant, provide
a detailed resource development plan that
explains: |
| |
|
How this
grant will leverage additional resources from
private and public resources |
| |
|
How this
grant and additional resource will promote
institutional development |
| |
|
How this
resource development plan fits into your organization’s
strategic plan |
| |
|
| FINANCIAL
INFORMATION (25%) Submit budget
information using the forms provided for income
and expenses. Refer to the document Budget
Items and Justification Guidelines for
any items you do not understand. Complete
attached budget forms (Federal
Form 424). |
| |
|
| ATTACHMENTS
AND OTHER SUPPORTING DOCUMENTS (10%)
Please provide the following attachments
and any relevant supporting documents.
- Organization’s annual operating
budget for current year
- Organization’s most recent audited
financial statement (if available) or
Form 990. If neither one of these is available,
provide the organization’s income
and expense report for previous year.
- Certification form signed by the organization’s
executive stating that he/she has read and agreed
to comply with the standards outlined in the
document entitled Guidance
to Faith-Based and Community Organizations on
Partnering with the Federal Government.
- Current board of directors’ list
with names, titles, employment affiliations,
constituencies Supporting materials such
as program or project brochures, newspaper
articles, letters of support, etc.
- One paragraph description of key staff
and volunteers, including qualifications
relevant to this request
Please return this information no later than
June 1, 2003, to:
Rev. Danny Cortez,
Senior Vice President
Nueva Esperanza, Inc.
4261 North 5th Street
Philadelphia, PA 19140
Phone: 215-324-0746
Fax: 215-324-2542
Email: www.esperanza.us
Applicants are encouraged to submit applications
online, or applications may be submitted
by standard mail or by fax.
If you have any questions or need assistance
with the application, please contact us by email
or by phone.
|
|
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