CHRIST CHURCH BENEVOLENCE APPLICATION 2016

Non-Profit Name:

Non-Profit AddressWebsite: ______

Contact Name:

Contact Address:

E-mail Address:

Telephone Number:

1. What is your organization’s mission?

2. Please place an “x” by whichever category best describes the focus of your agency. Check only ONE category:

☐ Infant & Early Child Wellness and Development☐ Job Assistance

☐ Youth Education☐ Hunger Assistance

☐ Youth Inclusion☐ Homelessness Assistance

☐ Youth Anti-Violence☐ Refugee Assistance

☐ Youth Arts☐ Ex-Offender Assistance

☐ Health & Wellness Services☐ Senior Assistance

☐ Mental Health Services/Counseling☐ Crisis Relief & Shelter

☐ Disability Assistance and Enrichment☐ Christian Education & Service/Pastoral Care

☐ Home Maintenance & Repair/Rehab

3. Our 2016 Request is: ______Projected Overall Funds to be Raised in 2016______

Is this a Project Request with a different Budget? If so, state Project Budget Amount______

4. 2015 Grant (if applicable): ______Total Funds Raised in 2015: ______

Please describe below precisely how the spent the 2015 Benevolence Grant was spent. Please be specific, but succinct. Please estimate the actual number of people served.

5. Top three sources of 2015 funding and rounded amounts from each:

1)

2)

3)

6. Average annual number of paid full time ______and part time employees ______

7. Top three highest paid positions in 2015:

Position / Annual Salary
1) / $
2) / $
3) / $
Sum of Top Three / $

8. Average annual number of volunteers ______

9. How long have you provided this service? ______

10. How will you spend this grant money if successful? Provide detail, please. Note that we cannot contribute to salaries of personnel.

11. How do you measure the positive outcomes of your programs? Please provide both quantitative metrics and qualitative observances.

12. In your own words, tell us briefly what it is that your non-profit does which brings you most satisfaction.

13. Christ Church parishioners actively volunteer with many different service organizations and we constantly are seeking to identify additional ways that we can help make a difference to others. Please let us know if there are ways in which our parishioners might help your organization and if so, who we might contact to get further information about this.

14. NOTE: Please also enclose (a) most recent Federal Tax Exempt Status [501(c)3] determination letter from the Internal Revenue Service, (b) the most recent Form AG-990 you filed with the Illinois Attorney General, and (c) actual 2015 financial results and 2016 Budget. Feel free to enclose additional information that you believe would be relevant to the Committee’s consideration of your grant request, keeping in mind that brevity is appreciated.

Thank you from the Benevolence Committee of Christ Church Winnetka. Good luck!

Office Use: Caseworker ______