an affiliate of Central Kansas Community Foundation
GEORGE TRIMBLE SPECIAL NEEDS CHARITABLE FUND
Grant Application
Application available online at .
Applications should be submittedonline.
Application due December 9, 2015
Organization Information
Name of Organization: ______
Website: ______
Mailing Address: ______
Number/Street
______
City State Zip
Telephone Number: (_____)______Fax Number: (_____)______
Executive Director/Top Executive Information
□ Mr. □ Mrs. □ Ms. □ Miss □ Dr. □ Rev. □ Gov.
Executive Director/Top Executive Name:
______First Middle Initial Last
Title: ______
Work Telephone Number: (_____)______Ext: _____
Alternate Telephone Number: (_____)______
Email Address: ______
Alternate Contact Information(if different than Executive Director/Top Executive)
□ Mr. □ Mrs. □ Ms. □ Miss □ Dr. □ Rev. □ Gov.
Alternate ContactName:
______First Middle Initial Last
Title: ______
Work Telephone Number: (_____)______Ext: _____
Alternate Telephone Number: (_____)______
Email Address: ______
Past Funding
Was the organization funded by the George Trimble Special Needs Charitable Fundin 2014?
□ Yes□ No
If yes, was a follow-up report submitted?
□ Yes□ No
If no, attachafollow-up report. (Access the electronical Follow-Up Form at .) (Allowed file extensions: pdf., doc., docx., xls., jpg.)
(You must submit a follow-up report for consideration.)
Funding Request
Please provide a brief description of the organization and the population served(maximum 100 words).
List the organizations board members or principal parties.
Project/Program Title: ______
Type of grant requested. (If applicable, indicate more than one category.)
□ New Project/Program
□ Existing Project/Program
□ Capacity Building
□ Capital
□ General Operating Support
□ Other ______
Please indicate which category best reflects the purpose of the request. (If applicable, indicate more than one category.)
□ Arts & Culture
□ Community Preservation & Revitalization
□ Emergency/Disaster Needs
□ Health & Human Services
□ Science & Education
□ Other ______
In 100 words or less, please summarize the project/program.
Approximate number of Butler Countyarea residents to be served by the project/program: ______
How will the project/program directly impact the communities across Butler County(maximum 100 words)?
Please explain how the project/program will provide assistance to the needy; relief to victims of fire, flood, or other natural disasters; promote public health, education, safety, or other public cultural activities; or promote the welfare and safety of the citizens of Butler County, Kansas and the surrounding area (maximum 100 words).
Time period of project/program (December 29, 2015 – September 1, 2016)(Grants may not be awarded retroactively for project/programs. Please see the highlighted time period and ensure that the project/program will not occur until after grants are estimated to be made. If your project/program has already happened or will happen prior to when grants will be made, it is not eligible.) : From: ______To: ______
Date when funds will be needed (no earlier than December 29, 2015): ______
Total project/program cost: $ ______
Total amount of funding requested from the George Trimble Special Needs Charitable Fund(not to exceed $3,000): $ ______
Total grant requests frequently exceed the amount of available funding. Is there aminimum grant amount acceptable for the project/program to proceed?
□ Yes□ No
If yes, what is the minimum grant amount acceptable for the project/program to proceed? $ ______
Is there any pending funding sources for the project/program?
□ Yes□ No
If yes, please identify any pendingfunding source(s) including amount(s).
Is the project/program cost greater than the grant request?
□ Yes□ No
If yes, how will the remaining balance be raised(maximum 50 words)?
Is the grant request greater than the cost of the project/program?
□ Yes□ No
If yes, how would the additional funding, above the amount of the project/program, strengthen the project/program(maximum 50 words)?
Please describe how the organization will use the requested funds(maximum 100 words).
How was the need determined for the project/program(maximum 100 words)?
Is there any additional supplemental materials(brochure, letter of support, etc.) that you would like to include?
□ Yes□ No
If yes, please attach one additional supplemental material (brochure, letter of support, etc.). (Allowed file extensions: pdf., doc., docx., xls., jpg.)
Itemized and Prioritized Budget
George Trimble Special Needs Charitable Fund Grant Request: $ ______
Support and/or Revenue
Is there any committed support and/or revenue for the project/program?
□ Yes□ No
If yes, please list committed support and/or revenue source(s) and the amount(s) below.(If there is more committed support and/or revenue sources than lines you may combine them.)
Support/Revenue Source 1: ______
Support/Revenue Amount 1:$ ______
Support/Revenue Source 2: ______
Support/Revenue Amount 2:$ ______
Support/Revenue Source 3: ______
Support/Revenue Amount 3:$ ______
Support/Revenue Source 4: ______
Support/Revenue Amount 4:$ ______
Support/Revenue Source 5: ______
Support/Revenue Amount 5:$ ______
TOTAL Support and/or Revenue: $ ______
Expenses
Please list the project/program expense(s) and amount(s) below(priority first).(If there is more expenses than lines you may combine them.)
Expense 1: ______
Expense Amount 1: $ ______
Expense 2: ______
Expense Amount 2: $ ______
Expense 3: ______
Expense Amount 3: $ ______
Expense 4: ______
Expense Amount 4: $ ______
Expense 5: ______
Expense Amount 5: $ ______
Expense 6: ______
Expense Amount 6: $ ______
Expense 7: ______
Expense Amount 7: $ ______
Expense 8: ______
Expense Amount 8: $ ______
Expense 9: ______
Expense Amount 9: $ ______
Expense 10: ______
Expense Amount 10: $ ______
TOTAL Expenses: $ ______
Budget Difference (TOTAL Expenses minus TOTAL Support and/or Revenue): $ ______
Is there any additional budget informationthat you would like to include?
□ Yes□ No
If yes, please attach additional budget information.(Allowed file extensions: pdf., doc., docx., xls., jpg.)
Declaration and Compliance
Doestheorganization possess a 501(c)(3) status under the Internal Revenue Service code?
□ Yes□ No
If yes, please attach proof of 501(c)(3) status.(Allowed file extensions: pdf., doc., docx., xls., jpg.)
If no, is the organization exempt under statute(i.e., educational institution, church, city, or county)?
□ Yes□ No
If yes, please identify the organization exempt under statute.
Name of Organization: ______
Contact Person: ______
Mailing Address: ______
Number/Street
______
City State Zip
Telephone Number: (_____)______Ext: _____
Email Address: ______
Please attach proof of exemption under statute. (Allowed file extensions: pdf., doc., docx., xls., jpg.)
If no, please identify the eligible organization that will serve as the project/programs fiscal agent.(Organization must possess a 501(c)(3) status under the Internal Revenue Service code or be exempt under statute.)
Name of Organization: ______
Contact Person: ______
Mailing Address: ______
Number/Street
______
City State Zip
Telephone Number: (_____)______Ext: _____
Email Address: ______
Please attach proof of project/programs fiscal agent’s 501(c)(3)status or exemption under statute. (Allowed file extensions: pdf., doc., docx., xls., jpg.)
Employer Identification Number (EIN): ______
We give permission to use our organization’s name and project/program in publicity.
□ Yes□ No
***********************************
I certify, to the best of my knowledge, that all information included in this application is correct. The tax exempt status of this organization is current. If grant is received through the George Trimble Special Needs Charitable Fund managed by El Dorado Community Foundation,an affiliate of Central Kansas Community Foundation, for the purposes described herein shall be restricted as stated herein.
______
Signature of Representative Requesting Grant Date
The George Trimble Special Needs Charitable Fund is managed by El Dorado Community Foundation, an affiliate of Central Kansas Community Foundation, a IRC § 501(c)(3) charitable corporation organized under the nonprofit corporation laws of the state of Kansas, with its principal office located at 301 North Main, Newton, Kansas, 67114.If you have questions or need further information, please contact Angie Tatro, CKCF Executive Director, at or 316.283.5474. Additional information posted at .
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