To Be Eligible to Apply, Your Organization Must First Meet the Following Requirements

Letter of InquiryPage 1

Letter of Inquiry

Organization Name:
Mailing Address:
City: / ST: / Zip:
Contact Name: / Title:
Phone: / Email:
Website:

To be eligible to apply, your organization must first meet the following requirements:

Is a not-for-profit organization. Tax ID# ______

Haveat least 25% of the total project cash in hand.

If your organization does not meet these requirements, you will not be considered for a grant.

What to Include in Your Letter of Inquiry:

Please be meticulous toinclude the following information. Check off each item once completed and initial at the bottom of your checklist.

Includemission statement or guiding principles and describe your organization’s successes and challenges

Size of staff and board

Constituency and geographic region served

Type of service you provide

Program case/business plan that supports your request

Factors that contribute to the need or opportunity

How many people it will help

How it will be sustainable once this ONE TIMEinitial funding has been exhausted

A proposed budget for the total cost of this project

Exact amount being requested from Portneuf Health Trust (should exclude your 25% cash in hand)

Annual budget information

Explain how this program expands health care, health education or focuses ondisease prevention and wellness

Explain how this request helps improve the health of the residents of southeastern Idaho and surrounding areas

Completed Cover Letter

2 Pages (3 pages maximum including this cover letter)Initials:______

Thank you for completing the FIRST PHASE of our grant process.Ifyour proposed project is chosen to advance in our process, you will be contacted for more information.

Email to:r if you prefer, send your Letter of Inquiry via US Postal Service to:

Portneuf Health Trust

Letter of Inquiry

500 South 11th Ave, Suite 503

Pocatello, ID 83201

~Include this page with your Letter of Inquiry~

Please use the form below to complete your up to two page letter of inquiry

Organization background:(Please include your mission statement or guiding principles, your organization’s successes and challenges, size of staff and board, constituency and region served, and the type of service you provide)

Project Overview:(List your program/business plan, factors that contribute to the need or opportunity, how many people it will help, and how it will be sustainable oncethisONE TIME initial funding has been exhausted)

Project Budget Information:

Please list each item you are requesting and its exact cost (add/delete as many lines as needed):

COST: / ITEM:
Equipment:
(Funding for acquisition of new equipment) / $ ______
$ ______
$ ______/ •
•
•
Capital:
(Funding forbricks and mortar projects) / $ ______
$ ______
$ ______/ •
•
•
Program:
(Funding for programs that create the capacity to enhance or promote health in our region. Operational funding for programs is discouraged) / $ ______
$ ______
$ ______
$ ______
$ ______
$ ______/ •
•
•
•
•
•

*Note: One of the requirements is that you must have at least 25% of the total project cash in hand.

Total Amount of Project: / $
Total Amount Requested from PHT: / $

Organization’s AnnualBudget Information:

Revenue / Expenses / Net Income (or Loss)
Current Year Budget:

How does this project improve Health?(Explain how this program expands health care, health education or focuses on disease prevention and wellness)