DISTRICT SIMPLIFIED GRANTS
Request and Agreement Form
CLUB______________________
For Grant Activities Taking Place During Rotary Year 20_____ - 20______
This District Simplified Grant Request and Agreement is entered into by the club as identified above and Rotary District 7850. In consideration of receiving this District Simplified Grant (DSG), the club agrees:
1. To utilize DSG funds to support short-term charitable, educational, and humanitarian projects that benefit a community. Funds provided by District 7850 will not be used for any purposes other than those considered eligible by The Rotary Foundation as described in the Terms and Conditions of DSG Award and Acceptance.
2. That is has received and read the Terms and Conditions of DSG Award and Acceptance and will abide by all stipulations set forth therein.
3. That information and requirements related to DSG will be communicated via the Club Member responsible to the District DSG subcommittee.
4. That funds provided by District 7850 will not be transferred directly or indirectly to or used to purchase goods or services destined for any country, entity, or person that is subject to economic or trade sanctions by the United States government, without the express written permission of The Rotary Foundation (sanctioned countries include Cuba, Iran, Iraq, Libya, and Sudan).
5. To defend, indemnify, and hold harmless Rotary International (RI), TRF, their respective Directors, Trustees, Officers, and employees (collectively “RI/TRF”) from any and all damages, losses, judgements, costs, fines, awards, liabilities, or expenses including without limitation reasonable attorney’s fees and costs of litigation, asserted or recovered from RI/TRF; that result or arise directly or indirectly from the implementation of the project.
6. That this agreement may be cancelled for any reason without notice upon the failure of the club to abide by the terms set forth herein. The club agrees to return any grant funds, in their entirety including any interest earned, should funds be misused or used for ineligible purposes and understands that it may be barred from the receipt of additional grants for up to five years.
By signing below, I certify that the Rotary Club of __________________________acknowledges and accepts the terms of this agreement and agrees to abide by the stipulations set forth therein. I authorize US$___________________in District Designated Funds to be identified to this grant request.
Dated this _______________________day of_________________20__________.
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Club Member authorized Print Name
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Club Member authorized Print Name
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Club Member authorized Print Name
DISTRICT SIMPLIFIED GRANTS
Application
ROTARY CLUB_____________________________
AMOUNT REQUESTED_______________________
CONTACT INFO FOR MINIMUM OF 3 CLUB MEMBERS WHO WILL OVERSEE THIS GRANT: (please print names in the order they should be contacted by the DSG committee with questions)
Name:__________________________Name:_________________________Name:__________________
Address:________________________Address:_______________________Address:_________________
H Phone:________________________H Phone:_______________________H Phone:________________
W Phone:_______________________ W Phone:_______________________W Phone:________________
H email_________________________H email________________________H email__________________
W email_________________________W email_______________________W email_________________
Please describe the project. How will it meet the needs of the community? What, specifically, will the grant money be used for?
Please describe your club’s involvement in the project. Is your club adding any additional money to the Grant? How will the community be involved?
How long will the project take to complete? What are potential pitfalls that could delay completion? Please show us a detailed expected timeline for the project.
DISTRICT SIMPLIFIED GRANTS
Application, page 2
How will your club promote this project in the local media?
If there is not enough Grant money for this year, could you do your project with less than what you have asked for? Could you delay implementation for a year? (if this is the case, someone from the DSG committee will be in touch with you to discuss options).
As the designated members of The Rotary Club of _____________________, we will promise to be stewards in good faith of this Grant money, understanding it comes 100% from the donations to the Rotary Foundation of District 7850 members three years ago.
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Signature Printed Name Date
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Signature Printed Name Date
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Signature Printed Name Date