District 7170 District Grant Application 05/11/19 Page 1 of 5

District 7170 District Grant Application 05/11/19 Page 1 of 5

Rotary District 7170

Simplified Grant Application

Please complete all sections of this application. Rotarians may use this form and attach additional pages as needed or may answer the questions below on blank paper, on the condition that the answers follow the same order as the application.

Incomplete applications will not be considered.

See A GUIDE TO MATCHING GRANTS (144-EN) for helpful information about completing this application.

1.PROJECT DESCRIPTION

Please describe the project, its objectives, and how they will be attained. Note: The project cannot be started until the District 7170 Grant application is approved, in writing, by The District Rotary Foundation Committee.

Estimated start date of project ______

Estimated completion date of project______

2. OTHER NON-ROTARY ORGANIZATIONS

If this project involves a cooperating organization:

1) Provide the name of the organization below;

2) Attach a letter of participation from that organization that specifically states its responsibilities and how Rotarians will interact with the organization in this project, and

3) Attach a letter of endorsement of the organization from the Rotarians in the project community.

Name of organization ______

Letter of participation from organization attached

Letter of endorsement from Rotary Club attached

3. RELATIONSHIP TO OTHER RI OR ROTARY FOUNDATION PROJECTS (OPTIONAL)

Is this project a Rotary International Matching Grant project? If so, please attach a completed official Matching Grant Application.

YesNo

4. COORDINATING COSPONSOR IN THE PROJECT COMMUNITY/COUNTRY

List the club(s) in the project community/country, which assumes (joint) responsibility for the project.

______

Club Club ID number (if known) District Community/Country

Project Committee: A committee of at least two Rotarians must be established in the project community/country. It is the committee’s responsibility to coordinate the project locally, monitor funds, and provide financial accounting to The Funds Distribution Committee (FDC) for the duration of the project.

Primary Contact Additional Contact

Name ______Name______

member ID number (if known) member ID number (if known)

Rotary position/title______Rotary position/title______

E-mail______E-mail______

Address ______Address______

street address street address

______

city / state / postal code city / state / postal code

Telephone ______Telephone ______

homehome

______

officeoffice

Fax______Fax ______

5. PRIMARY CLUB(S) SPONSOR

List the club(s) which will coordinate principal funding for the project and which will assume (joint) responsibility for the project.

______

club club ID number (if known) district

Project Committee: A committee of at least two Rotarians must be established by the sponsor club(s) to over-see the project for the project’s duration, even if it continues into another Rotary year.

Primary Contact Additional Contact

Name ______Name______

member ID number (if known) member ID number (if known)

Rotary position/title______Rotary position/title______

E-mail______E-mail______

Address ______Address______

street address street address

______

city / state / postal code city / state / postal code

Telephone ______Telephone ______

homehome

______

officeoffice

Fax______Fax ______

6. PROJECT BUDGET

Include a complete itemized budget for the entire project. Please use separate pages if necessary. Pro forma invoices, supplier price quotes, and/or other cost documentation must be attached for each item.

Pro forma invoices attached TOTAL______

7. PURCHASE OF EQUIPMENT, MATERIALS, OR SUPPLIES

1. Who will own equipment, materials, or supplies? (cannot be owned by a Rotary club or Rotarian)

2. Who will be responsible for maintenance, operating, and/or storage costs of the equipment/supplies?

3. If equipment/supplies will be shipped, have arrangements been made?

8. PROPOSED FINANCING

Please list all financing and indicate cash amounts.

Primary Sponsor Rotary Club Amount Contributing Cash

______

Other Rotary Clubs/Districts/Organizations

______

______

______

______

SUBTOTAL:______

Amount requested from The Fund Distribution Committee______

Additional funding from other sources______

TOTAL:______

9. ACTIVE ROTARIAN PARTICIPATION AND AUTHORIZATION

SPONSORSHIP AUTHORIZATION

All Rotary clubs or organizations involved in this project are responsible to The Fund Distribution Committee (FDC) for the conduct of the project and for reporting on it. The signature at the bottom of this page confirms that the sponsors understand and accept responsibility for the project. Sponsors may either sign this page or submit a separate letter of commitment.

Please use the following list to identify the activities demonstrating the active involvement of Rotarians in this project. If the list does not adequately describe the activities your club(s) will undertake, please attach a description on a separate sheet of paper.

Activities of Rotarians from outside the project community/country (at least one of the suggested activities below is required):

Suggested

Travel to work with project community or share technology and expertise at project site.

Donate or seek out donations of money beyond the matching amount, or goods and services.

Visit the project site.

Promote the project to local media and at Rotary district or zone meetings.

Attend major project events and ceremonies, where feasible.

Contact local Rotary cosponsor monthly.

Have involvement in project design.

Share expertise and technology via correspondence.

Arrange shipping supplies, equipment, or materials.

Maintain a relationship with the project community.

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.

• This application meets all Rotary International’s Grant criteria as stated in District 7170 Simplified Grant Distribution guidelines.

• The club(s) has agreed to undertake this project as an activity of the club(s) and organization(s) involved.

• We understand and will comply with the required Rotarian activities and reporting requirements as stated.

• We agree that interim reports will be submitted every six months from the time the grant is paid, and final reports will be provided two months after the completion of the project along with the Statement of Accounting and Original Receipts.

Club presidentOrganization president

______

please print name signature please print namesignature

______

title date title date

______

cluborganization

10. REPORT

Although both cosponsors are ultimately responsible for completing progress and final reports, the FDC require that one cosponsor take primary responsibility for submitting the reports to The District Rotary Foundation Committee as indicated below:

______

cosponsor signature name of club/organization

11. COMPLETION CHECKLIST

Before submitting your 7170 Grant Application, please take a minute to review this checklist and make sure that it is complete. If you have any questions or concerns, please contact The DRFC staff (see information at the end of the application).

Are there written funding confirmations from the club president(s) who will be in office during the year of the funding request?

Does the project meet all DRFC criteria (see the District Web site at

Have both the project community and the club/organization sponsor created committees to oversee the project? Are these individuals correctly listed on the application?

Have the responsibilities of the project club(s) sponsor and organization sponsor been outlined? Do they meet the requirements of a District Simplified Grants project?

Are there written commitments (or signatures on section 9 of the application) from each project sponsor?

Is there a pro forma invoice (cost estimate) from the supplier for each item?

Is a cooperating organization involved? If so, are there letters from 1) the organization, which specifically states how the organization will work together and how Rotarians will be involved and interact; 2) from the Rotary club in the project community indicating that it has knowledge of the organization and endorses the cooperative effort?

Have you made copies of all documents for your files prior to submitting them to The DRFC?

NOTE: You will receive a file number when the application is received by the District Rotary Foundation Committee. This does not indicate that the grant has been approved. You will receive a Letter of Acceptance if the DRFC approves your completed application.

Send the completed application and all attachments to:

An electronic version is preferred and will speed up the process.

Sam Koury, PDG, District 7170 District Simplified Grants Chair

5 Park Avenue

Oneonta, NY 13820

Phone: (607) 432-0354

E-Mail: