American Heart Association Kansas Alliance for Wellness
Supporting Food and Farm Councils
Request for Proposals
Policy Implementation Grant Proposal Template
Please email all proposal materials (application and required attachments listed on page 4) as PDF documents to: . Applications will be reviewed on a rolling/ongoing basis starting on August 1, 2016.
Food and Farm Council Applicant Information
Food and Farm Council Name
Address
City
County
State
Zip Code
Phone Number Please use the following format: (xxx) xxx-xxxx
Fax Please use the following format: (xxx) xxx-xxxx
E-mail Address
Website
Mission/Purpose of the Food and Farm Council
County(ies) served by the Food and Farm Council
Food and Farm Council Primary Contact
Prefix
First Name
Last Name
Suffix
Title
Phone Number Please use the following format: (xxx) xxx-xxxx
Food and Farm Council Project Information
Contact Person for this Project
Prefix
First Name
Last Name
Suffix
Position/Title
Phone Number Please use the following format: (xxx) xxx-xxxx
Project Start Date
Project End Date
Food and Farm Council Policy Implementation Questions
Describe how the local unit of government supports the Food and Farm Council.
(Please limit to 500 words)
What policy, system or environmental change does the Food and Farm Council plan to implement to increase access to and consumption of healthy foods and beverages?
(Please limit to 500 words)
Provide an outline of the planned activities you have identified related to this effort and the partners involved.
(Please limit to 1000 words)
Provide a timeline of the planned activities.
(Please limit to 500 words)
Describe the results/outcomes you hope to achieve.
(Please limit to 500 words)
Describe anticipated challenges and how they would be addressed.
(Please limit to 500 words)
Food and Farm Council Budget & Budget Narrative
Please complete the following budget and budget narrative section, as it relates to your proposed grant request for American Heart Association Kansas Alliance for Wellness consideration. Note: The grant amount requested must not exceed $15,000. Please also note that indirect expenses/funding (accounting/audit/legal fees, organizational rent, telephone or organizational utilities) will not be accepted as part of the budget.
Amount Requested: $______(this should equal the total from the below line-item budget)
Budget Line Items/Sections / Grant Request / Matching Funds, if applicable (internally committed or externally secured) / Overall Budget TotalConsultant(s)
Travel
Supplies
Equipment
Printing
Other: ______
______
______
TOTAL
Budget Justification:
Please succinctly provide a detailed budget justification/explanation for your request. There are generally three ways to describe the basis for a cost: actual cost (such as for consultant fees), vendor price lists or quotes (equipment, airfare, lodging), or prior experience (supplies). For budget justification areas/components, please focus on how requested funding support will be utilized. This rationale should correspond to the line items in the above budget presentation.
Consultant(s):
Briefly explain your needs for a consultant. For each consultant, indicate the person’s name (where possible), title or function (e.g., Jane Doe; Project Director), rate, and level of effort (e.g., number of hours or days) for each consultant.
Travel:
Justify any travel as a direct need of the proposed project. Describe the purpose and what is being proposed (mileage, car rental, airfare, lodging, etc.).
Supplies:
Justify any supplies required as a direct need of the proposed project. Describe the quantity and unit cost of each item.
Equipment:
Justify any equipment purchases as a direct need of the proposed project. Describe the quantity and unit cost of each item.
Printing
Justify any printing required as a direct need of the proposed project. Describe the quantity and unit cost of each item, if applicable.
Other
Explain the cost basis for other direct project costs that are part of this proposal (e.g., direct costs for postage, photocopying, data entry, etc.).
Attachments
This Food and Farm Council Grant Proposal Application requires submission of following documents in PDF format:
· Official Government Action Establishing the Food and Farm Council – must include signature (resolution, ordinance, proclamation, etc.) OR Signed Letter of Support from an Elected Official
· Food and Farm Council Bylaws
· Food and Farm Council Roster - must include sector represented by each member, years remaining in term and contact information
· IRS determination letter regarding 501(c)(3) status (or statement of governmental entity status if you are applying as a unit of government)
· W-9 Form (taxpayer identification number and certification)
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