BENZIE COUNTY COMMUNITY CHEST

Date of Application: _______________________________

Legal name of organization applying: ______________________________________________________________________________________

(Should be same as on IRS determination letter and as supplied on IRS Form 990)

Year Founded: ___________________________ Current Operating Budget: $_________________________

Executive Director: __________________________________ Phone Number: ________________________

Contact person/title/phone number

(if different from executive director): __________________________________________________________

Address (principal/administrative office): ______________________________________________________

City/State/Zip: __________________________________________________________________________

Fax Number: ________________ Email Address: _________________ Web Address:__________________

List any previous support from this funder in the last 5 years: _____________________________________________________________________________________

Purpose of Grant: (one sentence): _____________________________________________________________________________________

Dates of the Project: _______________________________ Amount Requested: $_____________________

Total Project Cost: $____________________________

Geographic Area Served: _________________________________________________________________

_____________________________________________________________________________________

Signature, Chairperson of Board of Directors

_____________________________________________________________________________________

Typed Name and Title

_____________________________________________________________________________________

Signature, Executive Director Date

_______________________________________________

Typed Name and Title

APPLICATION FORMAT:

Please provide the following information in this order. Using these headings, subheadings and numbers provided in your own word processing format, thus leaving flexibility for length of response.

A. NARRATIVE

1. Executive Summary

Begin with a half-page executive summary. Briefly explain why your agency is requesting this grant, what outcomes you hope to achieve, and how you will spend the funds if the grant is made.

2. Purpose of Grant

Statement of needs/problems to be addressed; description of target population and how they will benefit.

Description of project goals and objectives (measurable, if possible) and statement as to whether this is a new or ongoing part of the sponsoring organization.

Plans to accomplish goals and objectives.

Timetable for implementation.

Who are the other partners in the project and what are their roles?

Acknowledge similar existing projects or agencies, if any, and explain how your agency or proposals differs, and what effort will be made to work cooperatively.

Describe the active involvement of constituents in defining problems to be addressed, making policy, and planning the program.

Describe the qualifications of key staff and volunteers that will ensure the success of the program. Are there specific staff training needs for this project?

Long-term strategies for funding this project at end of grant period.

3. Evaluation

Plans for evaluation including how success will be defined and measured.

How evaluation results will be used and/or disseminated and, if appropriate, how the project will be replicated.

Describe the active involvement of constituents in evaluating the program.

4. Budget Narrative

Grant budget; use the Grant Budget Format that follows if possible.

On a separate sheet, show how each budget item relates to the project and how the budgeted amount was calculated.

List amounts requested of other foundations, corporations and other funding sources to which this proposal has been submitted.

In the event that we are unable to meet your full request, please indicate priority items in the proposed grant budget.

5. Organization

Brief summary of organization's history.

Brief statement of organization's mission and goals.

Description of current programs, activities and accomplishments.

Organizational chart, including board, staff and volunteer involvement.

B. ATTACHMENTS

1. Copy of the current IRS determination letter indicating 501c3 tax-exempt status.

2. List of Board of Directors with affiliations.

3. Finances.

a. Organization's current annual operating budget, including expenses and revenue.

b. Most recent annual financial statement (independently audited, if available; if not available, attach Form 990)

4. Letters of support should verify project need and collaboration with other organizations. (Optional)

5. Annual report, if available.