File FY________
Organization
Information
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Name of Organization
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Address
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City, County, State, Zip
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Federal Tax ID Number
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Phone
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Fax |
Web site |
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Name of Contact Person Regarding this
Application
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Title
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Phone
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E-mail
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Tax Status: |
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501(c)(3)* |
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Public Agency
(government created) |
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Unit of
Government |
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Other
(describe and attach appropriate
documentation) |
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*Please attach a copy of your IRS Determination letter, indicating
your organizational status.
If you plan
to use a fiscal agent please include contact information below,
including their Federal Tax ID Number. Fiscal agent must sign grant
agreement and accept oversight of the project. |
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Signature of Fiscal Agent
Proposal Information
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ProjectTitle:________________________________________________________________
(The SWIF may
alter the title to serve our publicity needs)
Project Start
Date: _______________________ Project End Date:
_____________________________
(Please allow
adequate time for processing)
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Please give a
2-3 sentence summary of request:
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Counties Served
by the project:
________________________________________________________________
Indicate the
projected number to be served by your project:
_____
People _____ Agencies _____Businesses _____Communities |
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Amount
Requested: $___________________ Total Project Cost:
$____________________ |
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Proposal Narrative
Provide a brief narrative
that answers each of the following points. Submit one original and one
copy of your proposal. This narrative should be less than two pages and
include:
Organizational History
Briefly describe your organization. Attach copy of IRS Determination letter,
if applicable.
Program Goals
What does the project hope to accomplish? What
is your focus?
Program Objectives
These are the clear, specific, and measurable outcomes of the project. State
the who, what, where, and when.
Methods
How are you going to accomplish the goals and objectives? What combination of
activities and strategies have you selected to bring about the desired results?
Why did you select this approach, given all of the possible approaches?
Evaluation
How will you measure your results?
Budget
Please fill out the attached budget page. In addition, provide a budget
justification, detailing the items listed on the budget page (i.e. consultant
hired for 200 hours at $25/hour). The more specific you are, the better.
If you have any questions,
please contact Collette Diemer, chairperson of the Heron Lake-Okabena Community
Foundation, at 507-793-2582 or
hlocf@ssc.hlo.mntm.org .
Please
submit the completed application to:
Heron Lake Community Foundation
c/o Becky Cselovszki
P O Box 97
Okabena, MN 56161
Authorization
I certify that the
information contained in this grant application is true and correct to the best
of my knowledge. I have the authority to apply for the funds requested.
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Name and title of
top paid staff or board chair: |
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Signature of top paid staff or board
chair: |
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Date: |
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File FY________
Budget
A. How much will your total project
cost?
_________
B. How much are you requesting from the <name of
fund> Foundation? _________
C. How much have you or will you receive from other contributors?
_________
(B + C must equal A)
D. List how this money and other contributions will
be spent:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
(The total of D must equal A)
E. How many hours do you estimate that people will
spend working on this project?
__________________________________________________________________
F. List
any in-kind contributions (In-kind contributions are gifts of goods or
services instead of cash):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
(When applying for a HLOCF Grant,
copy & paste this document into word. Then type in the information
needed for the application and print it out to submit it to the HLOCF.)
Heron
Lake-Okabena Foundation Grant Guidelines
Heron Lake-Okabena Grant
Evaluation Rubric
