Grant Request
Application instructions, deadlines and giving guidelines are posted on the U.S. Venture website (www.usventure.com/programgrants.htm). Please refer to instructions before submitting a request. Any questions may be directed to Megan Boelter at or (920) 243-5806.
Organization’s Legal Name: Address: City: State: Zip: Has the organization done business under another name? c Yes c No If yes, Organization Phone: Year established: _ Organization EIN: Organization Website: Organization Chief Executive & Title:
# of full-time employees:
# of part-time employees:
# of volunteers:
Organization Description: Briefly describe what the organization does. (250 characters max)
Program or Project Title: Grant Contact Title:
Email:
Phone:
Amount Requested: Project Budget:
Project Start Date: Project End Date: Date Applied: Project Summary: Briefly describe the project. (500 characters max)
# of people this request will support: # of people supported annually by this organization:
Counties & state served by this program:
The U.S. Venture/Schmidt Family Foundation places high priority on associate and shareholder involvement in the organizations it supports. List name(s), phone number and email address of U.S. Venture associate(s) or shareholder(s) supporting this request:
Project Narrative: Describe the project in detail, including the need, program goals and population served. (2,500 characters max)
Service Providers: List any other organizations in your service area addressing the same need described in this request.
Long-Term Funding Strategies: Describe the long-term funding strategies for this project.
Future Funding Requests: Do you anticipate this organization requesting funds from the U.S. Venture/Schmidt Family Foundation for this program or any other program in the next two years? c Yes c No If yes, please describe.
Project Funders: List committed and pending grant requests for this project.
Funding Source / Amount / Committed / Pending$ / □ / □
$ / □ / □
$ / □ / □
$ / □ / □
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POINT Questions: Is this organization taking part in the Northeast Wisconsin POINT initiative? c Yes c No
* POINT involvement is not required for grant submission.
Team Name: Does this project seek to address one or more drivers in the POINT initiative? c Yes c No
Describe how this project will impact the indicator(s) selected.
(1000 characters max)
Choose one impact area that best applies to this project.
Education, Jobs & Economy, Family Support & Social Connectedness, Physical Health, Psychological Health & Addiction, Human Services, Other
If other,
Measureable Outcomes: List up to three goal statements or measures of success for this project. Include specific expected outcome(s), timeframe and setting or population addressed. Goal Statement Example: Our networked improvement community aims to improve successful housing rates from 72% to 80% for pregnant and parenting young mothers between the ages of 18 and 24 and their children who are experiencing homelessness in Brown County by the end of 2019.
Past U.S. Venture Funding: List the date, amount and purpose of any donations received in the past five years from the
U.S. Venture/Schmidt Family Foundation, U.S. Venture Community Engagement Committee, Basic Needs Giving Partnership, Schmidt Family G4 Fund, or Express Convenience Centers.
Funding Body / Date / Amount / PurposeEndowment: Does this organization have an endowment? c Yes c No
If yes -> State the current endowment balance(s) and describe any restrictions on the funds.
Additional Information: Provide any additional information helpful to the evaluation of this request.
Please attach separately:
□ Project Budget
□ Current Annual Organization Budget
□ Current Organization Balance Sheet
□ End of Year Financials (previous 2 years)
□ Board of Directors Roster
□ 990 Form
□ Copy of 501c3 certification
Electronic Signature Date