Quick Impact Placebased (QuIP) Grant

Lead Applicant Organization:

Lead Applicant Name:______

This person will be the main point of contact for the announcement.

EVERY EFFORT IS MADE TO CONTACT ALL FUNDED PROJECTS FIRST BY PHONE BEFORE A PRESS RELEASE IS ISSUED.

Contact person/title:

Mailing address:

City:Zip Code:County: _

Phone:Alternate Phone: (Cell):______

Email: ______

I am the legal property owner? Yes or No

I have been given the right to make changes, updates or additions to this structure or space by the property owner? Yes or No

Proof of ownership or proof of allowance from property owner must be included in the attachment section

Amount Requested ($2,500- $5,000)$

Amount of Cash Match (if none write 0)$

Amount of In-Kind Match(if none write 0)$______

Total Budget (total of all lines above)$

Please Identify

Indiana State Senator Name: ______Email:______District: ______

Indiana State Representative Name: ______Email: District:____

List the Counties to be served by the Project: ______

Upon signing this request i am certifying that applicant is not in violation of any state or federal law, or municipal ordinances as of this date. no money is due and payable to any municipal, county, state or u.s. governmental agency or department, nor does the applicant have liens or potential liens which could jeopardize the completion of this project. I certify that I am able to make decisions for this organization and authorized to legally enter into contracts.

Applicant SignatureApplicant TitleDate

Question 1: Please provide a brief summary of your project. (Please limit to 500 words)

Include details such as what is it you want to do and why, who will complete the work and who will be responsible for the project, where will the project be located (include maps as attachments), when will it happen and how will you spend the money. These are the questions that should be answered, at a minimum. Be as detailed as possible here, tell your story and explain your project.

Question 2: How will the project help achieve the following goals? (Please limit to 500 words)

Enhancing Public Spaces-

Improving the Overall Quality of Life or Place in Your Community-

Creating a Connected Community-

Increase Tourism-

Question 3: How will you collaborate with other partners on this project? (Please limit to 500 words)

Include details such as if there are partners and who those partners are, how you came together for this common goal, and how you plan to work together to achieve your goal.

Question 4: How will you celebrate or promote this project? (Please limit to 500 words)

Include how you will promote the project, recruit volunteers to help, celebrate the kick off and/completion, etc.

Question 5: How does this project fit into the long term vision for your community’s quality of place initiatives or improvements? (Please limit to 500 words)

Include any details about what the lifespan of the project looks like. What does the next generation of this project entail. Tell us, overall, what impact you hope to have on your community through the accomplishment of this project.

Line Item Budget

Line Item Budget
Grant Request / Cash Match / In-kind / Total
Total Cost Estimate
$ / $ / $ / $
Program Costs These include specific details including cost breakdown for each item, the quantity and the price
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
Costs Subtotal / $ / $ / $
Total Grant Funds / $ / $
Total Match / $ / $
Total In-kind / $ / $
Total Project Budget / $

Clearly define number of items and cost of each in the table

Please assure your amounts are accurate and consistent throughout the application

W9 to be attached

Direct Deposit Form to be attached

Quick Impact Placebased (QuIP) Grant Program 1