District 7120 District Simplified Grant

District 7120 District Simplified Grant

DISTRICT 7120 DISTRICT SIMPLIFIED GRANT

PROJECTAPPLICATION FORM2015-2016

Rotary District 7120 Club ______

Street/PO Box ______

Town, NY Zip Code______

Name and Contact information for Person Responsible for Grant work

Name ______

Street/PO Box ______

Town, NY Zip Code ______

Email address ______

Phone numbers ______

Rotary District 7120 Clubs must use this form to apply for a Rotary 7120 District Simplified Grant and answer all the questions as outlined. An application for a scholarship grant must be submitted on the separate application form provided. If applicant chooses to re-type this application, the sequence of the grant questions must be followed. Submit grant to DSG Chairperson, Doris Marsh, no later than April 1, 2015 by sending an electronic copy to() and a hard copyto 2252 Gilbert Road, Dalton, NY 14836.

For the Rotary District 7120 2015-2016 year, District Rotary 7120 clubs are to note the following requirements for DSG writing:

  1. Grants may be used for local projects, small international projects, and scholarships.
  1. Clubs may apply for one project grant and one scholarship grant per Rotary year. The total of all grants applied for may not exceed $3,000.
  2. In order to receive any grant, clubs must be qualified. Qualification includes signing a Club Memorandum of Understandingand Addendum for the current Rotary year and having a minimum of two (2) members (preferably the president-elect and foundation chair) attend agrant management seminar.
  3. Submit Club MOU (Memorandum of Understanding) with addendum to Grant Chairperson - Chuck Turner at 60 Danforth Crescent, Rochester, N.Y 14618.
  4. Please note that all grant money will be disbursed upon receipt of the written final report which includes receipts for all purchases.
  5. While these grants do not need to be in an area of focus, they must meet the Mission of Rotary.
  1. All Rotary Clubs applying for DSGs are expected to make a financial contribution toward the final cost of their projects.

The mission of the Rotary Foundation of Rotary International is to enable Rotarians to advance world understanding, goodwill, and peace through the improvement of health, the support of education, and the alleviation of poverty.

A. PROJECT DESCRIPTION (BE CONCISE)

  1. What is the purpose of the project?
  1. Provide abrief description of the project.
  1. How will it meet the needs of the community?

4. How does this project meet the Mission of Rotary?

B. COOPERATING ORGANIZATIONS

List the cooperating organization(s), if any:

  1. Name of organization #1______

Name of Contact Person ______

Telephone # ______

E-mail address ______

Name of organization #2 ______

Name of Contact Person ______

Telephone # ______

E-mail address ______

(Use another sheet, if you have more than 2 cooperating organizations.)

  1. Attach a letter(s) of support/participation/acceptance from each cooperating organization that specifically statesthe organization’s responsibilities and how organization(s) will cooperate/work with Rotarians on this project. Also, have cooperating organizations state in their letter of support/participation that they will take ownership of the equipment, maintain it, operate it, and secure the items purchased.

C. PROJECT COMMITTTEE

A committee of at least two Rotarians must be established by the applicant to oversee the project for its duration, even if it continues into another Rotary year.

Primary Contact Secondary Contact

Name ______Address ______

E-mail ______

Telephone ______

  1. PROJECT BUDGET

Attach an itemized budget for the entire project. Provide Pro forma invoices, supplier price quotes, and/or other cost documentation as applicable.

  1. PURCHASE OF EQUIPMENT

Who will own equipment, maintain, operate, and secure items purchased with grant funds? Equipment cannot be owned by a Rotary Club or Rotarian.

  1. PROPOSED FINANCING

Rotary Club Share$

DSG Requested $

Cooperating organization(s) $

TOTAL$

NOTE:In the event your club receives partial funding or a reduce amount of the funds requested, will your club still go forward and complete theproject or do a revised version of your project? Yes____ No_____ Note: Checking “NO” will result in no award in the event the full amount of the requested grant cannot be awarded.

  1. AUTHORIZATION

By signing below, we are agreeing to the following

  • All information contained in this application is true and accurate, to the best of our knowledge;
  • The application meets the Terms and Conditions of District Simplified Grant applications;
  • The club has agreed to undertake this project as an activity of the club.

Current PresidentCurrent President-Elect

Name______

Signature______

Date______

H.REPORTS

Although both signatories above are ultimately responsible for completing

progress and final reports, one should take the primary responsibility for

submitting the reports to the District Simplified Grant Committee.

Final reports will be emailed within 30 days of project completion and not later than Tuesday, May 17, 2016 to DSG Vice-Chairperson Eric Schmidt at . Club must retain original of report and receipts in accordance with the Club MOU/Addendum and any club foundation policies.

By signing below I shall take primary reporting responsibility for the above project.

Name ______Signature______

Date______

  1. MEMORANDUM OF UNDERSTANDING has been submitted to Chuck Turner, District Foundation Committee Grants Chairperson 60 Danforth Crescent, Rochester, N.Y. 14618. Initial ______.
  1. The ______Rotary Club certifies it has contributed on a per capita basis $25 or more to the Annual Program Fund of the Rotary Foundation during the Rotary year 2013-2014.

K.DISTRICT APPROVAL

District 7120 Simplified Grant Committee has approved the above described

Application for use of District Simplified Grant Funds on ______in the amount of $______.

Attested by:

District Simplified GrantCommittee Chairperson

Name ______Signature ______

Date______

Revised 8/28/2014

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