District Grant 2016-17 TRF #DG1741497

District Grant 2016-17 TRF #DG1741497

/ Rotary Club Report Form
Rotary District Grant - District 5650
2016-2017 Rotary Year Grants

District Grant 2016-17 TRF #DG1741497

Form Submission Instructions:

- - Form at -> The Rotary Foundation-> Grants

- - Complete form “on screen”- - Send by email to:

- - Print and

- - Scan to create electronic copy

Rotary Club (Lead Rotary Club for multi-club projects):

Project Title (BRIEF - describe below):

This is a Progress Report - required for all projects not completed by December 31, 2016. For Progress Reports, only item 1.a. below is required; complete any other areas that you wish.

This is a Final Report. Projects are to be completed so that the final report can be submitted by March 31, 2017. (If projects are completed earlier, reports are to be filed within 30 days of completion,

  1. Project Description - briefly describe the project.
  2. For Progress Report
  3. Progress to date:
  4. Detailed plans to complete (include dates):
  5. For progress report, YOU MAY STOP HERE - nothing further is required on this report.
  6. For Final Report
  7. What was done?
  8. When and where did project activities take place?
  9. Who were the beneficiaries of the project?
  1. Rotarian involvement – Important- show Rotarian involvement besides providing grant funds.
    How many Rotarians participated in the project as volunteers:
    What the Rotarian volunteers did / provided:
  1. Non-Rotarians that benefit from this project (who, how many?)
  1. Community impact - what is the expected long-term community impact of the project?
  1. Public Relations/Media Coverage (Check for “yes” and enter short description):

Rotary Logo Placement (required)
Print Media (newspaper)
Broadcast Media (radio, TV)
Post on Rotary Club Central / Showcase
Club Website, Social Media
New logo was used / based on Rotary’s Visual Identity Guidelines at rotary.org – click here
  1. Role of Cooperating Organizations (if any):

(continue on back / page 2)

District Grant 2014-15 Report FormFront – Page 1

  1. Financial Report (not required for Progress Report)

The following items are all required – check mark indicates the item has been completed.

A separate bank account was established for managing all project funds (established by the Lead Club on multi-club projects) – THIS IS REQUIRED BY ROTARY INTERNATIONAL

All project funds – the District Grant Check as well as the funds from all participating clubs (including the Lead Club on multi-club projects) were deposited to the bank account established in the item above

Copies of bank statements (income) are scanned and attached to this report; for multi-club projects, copies of the checks received from all clubs, including the Lead Club and deposit tickets detailing the deposits are to be provided

Copies of bank statements (expenses) including check images (front and back), showing all checks paid out on the project are scanned and attached to this report

Actual expenditures are to be listed below and must be supported by receipts; attach scanned copies of receipts; actual receipts must be retained by the club and be available for 3 years in case of an audit of the project/funding

Income (for multi-club projects, list each club and the amount provided)Amount

1. District Grant funds received from the District
2. Rotary Club funds (minimum to earn match required for each club)
Rotary Club
Rotary Club
Rotary Club
Rotary Club
Rotary Club
Rotary Club
3. Other funding (specify)
Total Project Income

Actual Expenditures (please be specific and add pages as needed)

Total Project Expenditures
  1. By signing this report, I confirm that, to the best of my knowledge, these District Grant funds were spent only for eligible items in accordance with The Rotary Foundation and District-approved guidelines, that all of the information contained herein is true and accurate, and that the requirements outlined in the memorandum of understanding were met. For multi-club projects, this form is to be signed by the Lead Club.

Certifying Signature Date:

Printed Name of SignerRotary Club Name

District Grant 2014-15 Report FormBack– Page 2