BAINBRIDGE COMMUNITY FOUNDATION

Marge Williams Office Center

221 Winslow Way West, Box 305

Bainbridge Island, Washington 98110

GRANT APPLICATION TO THE BAINBRIDGE COMMUNITY FOUNDATION

FOR THE C. KEITH BIRKENFELD BEQUEST

Applications should be submitted to the Bainbridge Community Foundation, attention

David Veterane, at the above address no later thanNovember 30th, 2007 by 5:00PM.

Organization Information:

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Name of Applying Organization

______

Address

______

Phone

______

Email

______

Executive Officer/Principal Contact(s)

Nonprofit Organization Information:

Please attach a copy of your current IRS determination letter.

Employer Identification Number (EIN): ______

Please provide a list of your Board of Directors, Officers, and staff.

Please provide a short history of your organization and a copy of your mission statement.

Proposal Summary:

Please provide a brief summary highlighting the essential features of your request:

Evaluation of Capital Project:

Describe how you will determine the success of this project. Include goals for increased service to clients, increases in revenue (if appropriate), reduction or increases in operating expenses as a result of this project, and any other relevant success factors.

Provide the name(s) of the individual or individuals who will assess and report the results.

If a capital campaign is involved, please describe the campaign plans. Please provide fund raising goals, timetables, the leadership team, etc. What percentage of the total capital campaign does this request from the Birkenfeld bequest represent?

Project and Organizational Information:

Project Start Date:______End Date: ______

Amount Requested: ______

Total Project Budget:______

Please provide the following additional information:

  • Detailed, itemized capital budget for this project.
  • Amount the organization is contributing from operating and/or reserve funds.
  • Amount contributed by the Board for this project.
  • Amount anticipated from fundraising.
  • Amount expected from loans.
  • List of other foundations or sources to which you have submitted applications for funding for this project. (Please indicate whether funds have been committed, declined or are pending).
  • Audited financial statements for the past three fiscal years.
  • Organization’s operating budget for the current fiscal year.
  • Organization’s projected operating budget for the year following the completion of the capital project.
  • Organization chart, number of full and part time staff, number of volunteers.

NOTE: The Birkenfeld Will does not include a deadline for disbursement of the bequest nor does it require that the funds be disbursed to only one deserving capital project. The Bainbridge Community Foundation reserves the right to divide the total funds available among one or more deserving projects and/or to reject any grant applications that do not meet all of the requirements set forth in Mr. Birkenfeld's Will and/or its additional criteria. The Bainbridge Community Foundation further reserves the right to grant only a portion of the total funds available and to reserve all or a portion of the total funds available for future grant cycles.

Signatures and acceptance of conditions by applicant organization:

I/We am/are an elected officer(s) and/or employee(s) of the nonprofit organization submitting this application and have been authorized by the board to submit this application to the Bainbridge Community Foundation. We hereby agree to accept and comply with all of the conditions and criteria set forth above in this Application Form.

By:______

Title

By:______

Title

Dated:______