APPLICATION CHECKLIST AND SIGN-OFF 2016-17
ORGANIZATION: ___________________________________________
PROGRAM FOR WHICH GRANT IS SOUGHT: ________________________
AMOUNT REQUESTED:____________________________________________
SISTER/ASSOCIATE/COMPANION REQUESTING GRANT:______________________
The check-off below is designed to insure that all relevant materials are included in your grant packet. Please check that each one is present or indicate why an item might not apply to your program/organization.
The following have been included in this packet: (check all those that apply)
Application Cover page ____ Grant Proposal ______
Executive Summary ____ Board of Directors ______
Program Budget ____
The following information, requested above, is not applicable to our organization:
(Please note-though not required to be submitted with your application, organizational documents such as audited financial statement, organizational budget, etc. must be available upon request by the Committee during the review period).
Person submitting grant: _____________________________________
(MUST be a Sister of Mercy/Associate/Companion from the Mid-Atlantic Community)
Email address:_____________________________________
If proposal is approved, check should be made payable to:
Name: __________________________________________________
Address: ___________________________________________________
____________________________________________________
MID-ATLANTIC MINISTRY FUND
APPLICATION COVER PAGE 2016-17
Organization submitting proposal: _______________________________ Date: ___________
Organization’s Address: ____________________________________________________
____________________________________________________
Contact info: Phone: ___________________________ Fax: _______________________
e-mail: _____________________________ website: _____________________
Organization Executive Director: ______________________________________
Person Submitting Proposal: _____________________________________
()
Indicate your relationship to project/program:
____ full time employee ___ part time employee ____ Volunteer ____ Board Member
Summary of Project:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Projected Start Date: _________________ Completion Date: ________________
Total Cost of Project:: _____________ % of total Requested from Ministry Fund: __________
Amount raised through other sources: Public funds: ______________ Donations: __________
Rec’d a previous grant from the Ministry Fund: ___yes __no. Year:_____ Amount: _________
Other kinds of financial support received from the Mid-Atlantic Community in the last year (i.e. Sister’s salaries, free space usage, etc.):____________________________________________
Do you anticipate any changes in this financial support from the Mid-Atlantic Community over the next year? __________________________________________________________________
Organization Budget for last fiscal year: _______________________
Type of request & amount: Planning (up to $10,000) ______ Ministry: (up to $15,000) _______
GRANT PROPOSAL
Organization:__________________________________________________
Project:_______________________________________________________
Amount Requested:_____________________________________________
Submitted by: __________________________________________________
Executive Summary:
In one page please highlight the significant elements of your proposal and what makes your organization the one who can effectively accomplish the project.
Proposal Narrative
In a maximum of 4 pages, answer the following:
Brief history of your organization, its mission, present-day services
Description of project/program for which your organization seeks funding
Description of population being served (number, demographics, etc.)\
Number of full and part-time staff for the project/program and brief indication of their qualifications
Specific goals, objectives of the project/program and how you will measure success/effectiveness (evaluation procedures)
Decision-making processes used in the project/program, with attention to how it involves those served in developing and evaluating services
Relationship of the project/program to the Direction Statement and Critical Concerns of the Sisters of Mercy of the Americas and Mid-Atlantic Community
Specific information about how the project/program will be financed if it is on-going
Budget for project/program, using budget page provided with attachments for clarifications and other sources of funding as needed
Financial Summary Budget Format
Program/Project Title: _________________________________________________
PROJECTED PROGRAM/PROJECT BUDGET
1. Operating Income Sources Amount
A. Mid-Atlantic Grant Request: _________________
B. Other Income/Funding Fees: ________________
Government/Public Funding: ________________
Other (specify sources and amounts) ________________
In-kind contributions (explain in clarifications) _________________
Total Projected Income __________________
2. Operating Expenses (include those that apply)
A. Salaries: ________________
B. Benefits __________________
C. Rent ___________________
D. Utilities & Heat ___________________
E. Telephone/postage ___________________
F. Training: ___________________
G. Office Supplies ___________________
3. Other Program Expenses (please specify)
Equipment purchases __________________
Transportation costs __________________
Marketing/advertising __________________
Other (please specify) __________________
Administrative/Overhead __________________
4. Total Projected Expenses ____________________
J. Projected Program Profit (Deficit) ____________________
K. Budget clarifications: explain here or on an attached page any budget explanations you wish to include
Organization: _________________________________________________________
Revised 11/28/16 ccm
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