2010-2011 FALL Health Care Grant Application Form                                                  Download Microsoft Word Version

 

Name of Organization AS SHOWN ON IRS DETERMINATION LETTER (BOLD & ALL CAPS):_____________________

 

Address:

Executive Director (Name & Title):                                  Contact Person for Grant Proposal (Name & Title):

Phone + Ext.:                                                                 Phone + Ext.:

E-mail:                                                                          E-mail:

 

I.  Mission Statement (LIMIT to 1 Sentence ONLY – State the purpose of why the agency exists):

 

II. USING BULLET POINTS, describe the programs & services of the nonprofit that holds the tax exempt status.  USING BULLET POINTS, include statistics on # of clients/patients served each month and annually; # of FTE staff in Program Services, Management & General and Fundraising; and # of units/beds along with a description of facility {if in-house program}:

 

III. ORGANIZATION’S CURRENT FISCAL YEAR OPERATING BUDGET (Use the exact budget categories below):

Fiscal Year:  MM/DD/YYYY – MM/DD/YYYY
OPERATING INCOME	AMOUNT	OPERATING EXPENSES	AMOUNT
Service Fees/Program Income	$	Program Services	$
Government Sources	$	Management & General	$
Endowment & Interest	$	Fund Raising	$
Contributions From:		Miscellaneous (LIST)	$
-Individuals	$
-Corporations	$
-Foundations	$
-Special Events (net amount)	$
-Board of Directors	$
-Other	$
Total Contributions	$
Miscellaneous (LIST)	$
TOTAL OPERATING INCOME	$	TOTAL OPERATING EXPENSES	$

 

IV. GRANT PROJECT-Please check 1 that describes the purpose of the grant:

____ Maintain Current Program/Services  ____ Expand Current Program/Services  ____ Add New Program/Services

1. Project Title:

2. Executive Summary of Proposed Health Care Project/Program (LIMIT to 3-5 sentences):

3. Grant Request: $

4. Project Budget: $

5. Describe the purpose of the grant and how our grant funds will be used:

a)  Describe the proposed health care project & how it relates to your agency’s mission.  INCLUDE total number of clients/patients to be served by the proposed health care project, number of additional staff needed and the location of the project. 

b)  State expected health care outcome(s) from the proposed project & describe how you will measure the outcome(s).

c)   Provide a timeline of one (1) year for the proposed health care project (grant funds must be used within 1 year).

d)  Provide an itemized income & expense budget for the proposed health care project using the following format.  Explain any deficits in a footnote.  You may add rows as needed, within the 3 page limit of the grant application.

 

INCOME:  Provide Funder’s Name, Grant Amount & if grant is pending or secured				EXPENSES:  Use BOLD TYPE to highlight the expenses that are expected to be paid with the Patron Saints Grant & Include the Project’s General Operating Expenses
LIST each source of pending funding	$			LIST Project Personnel - Hrly. Rates x # of hrs. &  Professional Titles	$
Patron Saints Foundation (should match #3. Grant Request above)	$	Pending		Subtotal Project Personnel	$
Subtotal of Pending Grants	$			LIST Project Overhead/Admin. Expenses	$
LIST each source of secured funding	$			Subtotal  Project Overhead	$
Subtotal of Secured Grants	$			LIST Project Materials/Supplies Expenses	$
				Subtotal Project Materials	$
TOTAL INCOME for Project	$			TOTAL EXPENSES for Project	$

 

 

V.  Application SUBMISSION Procedures: 

 

Deadline:  Applications must be postmarked on or before Midnight, October 1, 2010.

 

PLEASE USE REGULAR U.S. MAIL SERVICE TO SEND IN YOUR GRANT PROPOSAL.   DO NOT drop off your proposal.  To avoid delays in delivery, do not use delivery services, certified or return receipt requested services.  To ensure compliance with the stated post mark deadline, request a Proof of Mailing slip from the post office.

 

Please follow the grant application format EXACTLY.  Include the question & then your response – DO NOT WRITE “SEE ATTACHED.” The grant application may not exceed 3 pages for Sections I – IV.  The required attachments do not count towards the 3 page limit.  The font size cannot be less than 11 point. 

 

The grant application package must include the following:  A COVER LETTER IS NOT REQUIRED

 

1.       Two (2) copies of the three-page grant application (one copy stapled & one copy clipped with a paper clip);

 

2.       Send an e-mail to patronsaintsfdn@sbcglobal.net with a MS Word document attachment of the 3-page grant application;

 

3.       A signed Accountability Statement that the funds will be utilized as stated in the grant application, as follows:

This grant application from (Legal Name of Public Charity)   to the Patron Saints Foundation for a grant of $______ to be used for ____________________________________ is hereby submitted; and, in the event said grant is made, either in whole or in part, the funds so granted will be used solely for the purpose specified above. 

Date: _______________________           Executive Director’s Signature: ________________________________;

 

4.       Two (2) copies of the Board of Directors List that includes their name, board title, city of residence and professional affiliation.  At the bottom of the list, for the last completed fiscal year, indicate the % of board members that supported your agency, the total amount of direct contributions and the total amount raised by the board (do not include direct contributions in this last figure) (one copy stapled & one copy clipped with a paper clip);

 

5.       Financial Information:

a)      Most recent audited financial statement; AND,

b)      First page of the most recent IRS 990 + One complete copy (stapled) of the most recent 990 with ALL attachments, schedules & statements;

c)      If your organization does not have both of the above stated financial documents, submit the document you have and also submit a Balance Sheet along with an Income Statement for the most recently completed fiscal year;

 

6.       Please include a copy of the organization’s IRS 501(c)(3) Determination Letter stating that the agency is a public, tax-exempt charity & not a private foundation (stapled); OR, (ONLY WHEN APPLICABLE) a copy of the Face Page and the page on which the Applicant's listing is found in the current edition of the Official National Directory of the Applicant's Sponsoring IRS recognized Church or Public Charity, with a copy of the IRS Group Ruling Letter to the Sponsoring Organization for its current National Directory Listing of its sponsored organizations which are covered by its Group Ruling and in which the Applicant is identified as  covered by that Group Ruling (stapled);

 

7.       A completed H.R. 4 Self-Certification Form on applicant’s letterhead, as follows: (Legal Name of Public Charity) with EIN of ________,  is a 501(c)(3) organization with a designation under IRS section 509(a) as an organization described in: (PLEASE SELECT ONLY ONE) ______   Section 509(a)(1)  OR, ______   Section 509(a)(2)  OR, ______   Section 509(a)(3).

 

 

I declare that I am authorized to sign this self-certification form on behalf of the above organization and it is true and correct to the best of my knowledge.

 

Date: _______________________           Executive Director’s Signature: ______________________________________________;

 

8.    Place all the above documents, in the order listed, in a file folder with the organization’s name on the file folder tab.