DISTRICT 5390 SIMPLIFIED GRANT

CLUB APPLICATION

Please print or type all information and use additional sheets of paper if necessary.

1. CLUB(s): ______

2. Describe the project, its location, and its objectives. Will it proceed without this grant?

Estimated Start Date: ______Estimated Completion Date: ______

3. Describe how the project will benefit the community and/or improve the lives of the less fortunate.

4. Describe non-financial participation by Rotarians in the project (i.e., SPECIFIC Rotarian Activities).

5. Project Contacts: Two Rotarians must be listed who will provide oversight and management of the
project funds.
______

Primary Contact Name Rotary Position/Title

______

Address City, State, Zip

______

Telephone Fax

______

E-mail

______

Secondary Contact Name Rotary Position/Title

______

Address City, State, Zip

______

Telephone Fax

______

E-mail

6. Committee Chairs: The Club must have these committees to be eligible to receive a District Simplified
Grant.

______

Club’s Foundation Committee Chair

______

Address City, State, Zip

______

Telephone Fax

______

E-mail

______

Club’s Grants Committee Chair

______

Address City, State, Zip

______

Telephone Fax

______

E-mail

Page 2 of 3, District 5390 Simplified Grant Application

7. How will the general public know this is a Rotary-sponsored project? Please provide details, e.g.,
publicity in a newspaper, radio, television, display of the Rotary wheel, etc.:

8. Cooperating Organizations: If the project involves a cooperating organization, please provide the name of
the organization below and attach a letter of participation from that organization that specifically states its
responsibilities and how Rotarians will interact with the organization in the project. By signing this
application, the Rotarians sponsors endorse the organization as reputable, responsible, registered with
the project country, and acting within the project country.

______

Name(s) of Cooperating Organization(s)

9. Budget: Please include a complete, detailed, and itemized budget for the entire project, listing item,
vendor/contractor and amount. Supporting documentation utilized for the development of this budget may
be requested. Be sure and include pro forma invoices of all items costing $1000 or more.

10. Total Cost in US$: ______

Club Contribution $: ______Amount Requested from District: $______

11. Authorization: All Rotary clubs/districts involved in this project are responsible to The Rotary Foundation
for the conduct of the project and for reporting on it. The Signatures on the application confirm that the
sponsors understand and accept the responsibility. The signature of the sponsors also affirm that all
information in this application is true and accurate, to the best of their knowledge.

CLUB PRESIDENT: As President of the Rotary Club of ______

I hereby affirm that the Club has voted to undertake this project as an activity of the club.

______

Name, Printed

______

Signature Date

GRANT APROVED BY DISTRICT ______GRANT DENIED ______

______

Signature, District Grants Committee Chair

DISTRICT GOVERNOR: As Governor of District 5390, I hereby affirm the use of $______, US$,
from my District’s Simplified Grant Funds for this project.

______

Name, Printed

______

Signature Date

Page 3 of 3, District 5390 Simplified Grant Application

Individual Project Summary

District Simplified Grant # ______

Note: Rotarians completing an individual project summary should return this form to their District Leadership or to the District Simplified Grant Committee established at the district level.

Project Title: ______Rotary Club of ______

Report Type:  Progress Report

Provide an itemized statement detailing how grant funds have been expended to date.

 Final Report
Provide an itemized statement detailing how grant funds were expended on this project
from its implementation through completion.

COMMUNITY IMPACT:

1. Provide detailed information regarding the project and its beneficiaries, How many non-Rotarians
benefited from this project? ______How were they helped?

2. How has the project provided community members with specific skills or knowledge that will allow them to
help themselves?

3. If a cooperating organization was involved, what was its role?

ROTARIAN INVOLVEMENT:

1. How many Rotarians participated in the project? ______

2. How did they participate?

3. Provide an overview of the project spending below (retain receipts of all expenditures):

Items Purchased – Project Expenses / Cost (in local currency)
Total funds expended in local currency $

4. By signing this report, I confirm that District Simplified Grant funds of ______(local currency), were spent in accordance with Trustee approved guidelines and that all of the information contained herein is true and accurate. Receipts for all expenses will be retained for at least three years in case of audit.

______

Certifying Signature Date