Foundation Form

 
Date* Amount requested*
TYPE OF REQUEST
This request is for: *
Program/Project Title: *
Organization Information
Organization Name*
Address* City* Zip*
Country* State/Province*
Telephone* Fax
Email*
Executive Director* Telephone*
Name/Title of contact person* Telephone*
TYPE OF ORGANIZATION
Type of organization: *
Enter if other (specify) is checked   
Is your organization tax exempt under 501c(3)
501 c(3) # Annual organization budget for current year *
$
BUDGET
Annual Budget of specific program for which funds are requested *
$
Percent of contributions dispersed:
Programs %
Education %
Fundraising %
Management Expenses %
Total %
Geographic Area*
Staff
Staff composition in numbers:
Professional Support
Paid Full-time
Paid Part-time
Volunteers
Interns
Other
Totals
Time frame in which the funds will be used:
From * To *
 
Summarize the purpose of your request (5 sentences or less)*
 
Summarize the organization's mission (2-3 sentences)*
 
How will you measure the effectiveness of your activities *
 
What is the future of the program or project beyond the grant period? *
List other private and funding sources for this particular request.
(Click the Add button after each row entered)
Funding sources - To date Amount Status Date Received Action
 
 
Organizational Budget(last fiscal year)
Expenses * $ Revenues * $
 
ORGANIZATION INCOME FISCAL YEAR: *
 
Source Amount 
Support
Government grants $
Foundations $
Corporations $
United Way or other federated campaigns $
Individual contributions $
Fundraising events and products $
Membership income $
In-kind support $
Investment income $
 
Revenue
Government contracts $
Earned income $
Other(specify)
$
$
$
$
 
Total Income $
 
 
ORGANIZATION EXPENSES FISCAL YEAR: *
 
Item Amount 
Salaries, wages and benefits $
Insurance and/or other taxes $
Consultants and professional fees $
Travel $
Equipment $
Supplies $
Printing and copying $
Telephone and fax $
Postage and delivery $
Rent and utilities $
In-kind expenses $
Depreciation $
Other(specify)
$
$
 
Total Expenses $
 
 
Difference (Income less Expenses) $
Program/Project Budget (if applicable) $
Fiscal Year *  
Source Amount Committed Amount Pending*
Support
Government grants $ $
Foundations $ $
Corporations $ $
United Way or federated campaigns $ $
Individual contributions $ $
Fundraising events and products $ $
Membership income $ $
In-kind support $ $
Investment income $ $
Revenue
Government contracts $ $
Earned income $ $
Other (specify)
$ $
$ $
Total Income $ $
* Note: Pending sources of support include those requests currently under consideration.
PROGRAM/PROJECT EXPENSES
Item Amount
Salaries and wages (break down by individual position)
$

$

$
$
Subtotal $
Insurance, benefits and other related taxes $
Consultants and professional fees $
Travel $
Equipment $
Supplies $
Printing and copying $
Telephone and fax $
Postage and delivery $
Rent and utilities $
In-kind expenses $
Depreciation $
Other (specify)
$
Total Expense $
Difference (Income less Expense) $