CHRIST CHURCH BENEVOLENCE APPLICATION 2017
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☐ Volunteer Coordination
3. Our 2017 Request is: ______2017 Budget is:______
Is this a Project Request with a different Budget? If so, state Project Budget Amount______
4. 2016 Grant Amount (if applicable): ______2016 Budget was: ______
Please describe below precisely how the spent the 2016 Benevolence Grant was spent. Please be specific, but succinct. Please estimate the actual number of people served.
5. Top three sources of 2016 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 2016:
Position / Annual Salary1) / $
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.
13a). 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.
13b) ☐ Check here if you approve publishing your organization’s name, contact information, and nature of volunteer opportunities (based on information provided in 13a above) on the christchurchwinnetka.org website, which will be available to the public.
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 2016 financial results and 2017 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 ______