Rural Partners of Michigan Community Grant Award Application
Date of Application:______Federal E.I.N.#______
Legal name of organization applying:______
(Should be same as on IRS determination letter and as supplied on IRS form 990)
Year Founded:______Current Operating Budget: $______
Executive Director: ______
Contact Person/title (if different from Executive Director):______
Address (principal/administrative office):______
City/State/Zip: ______E-Mail:______
Phone Number:______Fax Number: ______
List any previous support from this funder in the last five years: ______
______
______
Project Name: ______
Purpose of Grant (one sentence): ______
______
Dates of the Project: ______Amount Requested: $______
Total Project Cost: $______
______
Signature, Chairperson, Board of Directors Date
______
Typed Name and title
______
Signature, Executive Director Date
______
Typed Name and title
Grant Request
Amount Requested: $______
To which focus issue would this project most closely relate? Focus areas include:
- Agriculture
- Broadband Access and Adoption
- Economic Development
- Education
- Health
- Housing
- Renewable Energy and Energy Conservation
- Rural Philanthropy
- Transportation
- Other Rural Development/Community Economic Development Projects
______
______
In one or two sentences, tell us about your work and how it addresses the focus issue you selected:
______
______
______
What results do you expect to produce? (i.e. the benefits that your project will seek to achieve)
______
______
______
How will you know when you’re successful?
______
______
______
GRANT BUDGET FORMAT
Please provide the following information in the order specified. Use the headings, subheadings and numbers provided in your own word processing format, for specific itemization of line items when appropriate.
- Organizational Fiscal Year: ______
- Time period this budget covers: ______
C. Expenses: include a description and the total amount for each of the following budget categories, in the following order:
Amount requested from Total Project Expenses this Organization
Salaries $______$______
Payroll Taxes $______$______
Fringe Benefits $______$______
Consultants and Professional Fees $______$______
Insurance $______$______
Travel $______$______
Equipment $______$______
Supplies $______$______
Printing and Copying $______$______
Telephone & Fax $______$______
Postage & Delivery $______$______
Rent $______$______
Utilities $______$______
Maintenance $______$______
Evaluation $______$______
Marketing $______$______
Other (specify) $______$______
Total Amount Requested$______Total Project Expenses$______
D. Revenue: include a description and the total amount for each of the following budget categories, in the specified order. Please indicate which sources of revenue are committed and which are pending.
CommittedPending
1. Grants/Contracts/Contributions
Local Government$______$______
State Government$______$______
Federal Government$______$______
Foundations (itemize)$______$______
Corporations (itemize)$______$______
Individuals $______$______
Other (specify)$______$______
CommittedPending
2. Earned Income
Events $______$______
Publications $______$______
3. Membership Income$______$______
4. In-Kind Support $______$______
5. Other (Specify) $______$______
Total Revenue$______$______
Completed applications can be emailed to Jessica AcMoody () or faxed to 517-485-3043 attn: Jessica AcMoody. The deadline for submission is 5:00pm on October 2, 2017.