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Rotary International District 5580 Complete and return via email,

with all documentation to:
District Grant David Gottenborg
Club Report Form District Grants Subcommittee Chair

Report Instructions

·  Project and Activities must be completed within 24 months following disbursement of funds from District 5580.

·  Progress reports are required every 12 months, and a final report is required within two months of the full expenditure of grant funds.

·  Complete and return via email with all documentation to the District Grants Subcommittee chair. This includes, but is not limited to, banking financial statements and purchasing receipts. The report must be signed and dated prior to submission. A scanned document showing the Certifying Signature is acceptable. Reports submitted without a signature will be returned.

·  Keep a copy of each report for your records, along with receipts for all expenditures, for a period of at least 3 years following closure of the grant.

·  Do not send the report or receipts to TRF unless requested.

·  The report MUST be typed. Hand written reports are not acceptable and will be returned.

·  For consistency purposes, please use only US$ currency for the whole report.

·  An article with picture(s) for display at Rotary International District 5580 events (The Rotary Foundation Event, District Conference (Project Fair), and/or District Assemblies including GMS) and used in district publications (e.g. the Cross Currents newsletter) is suggested.

·  If a project clearly demonstrates Rotarian involvement and is worthy of publication, you may choose to complete an RI Newstip Form, available on the RI website at www.rotary.org. Please attach action photos showing the beneficiaries or showing active Rotarian involvement.

Complete and return this form electronically with all documentation to:

David Gottenborg

District Grants Subcommittee Chair

District Grant Number:

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To be completed by Rotarians. Return this form to District 5580.

Rotary Club:
Project Title:
Progress Report / Final Report
Project Description

1. Briefly describe the project. What was done, when and where did project activities take place, and who were the beneficiaries?

2. How many Rotarians participated in the project?

3. What did they do? Please give at least two examples.

4. How many non-Rotarians benefited from this project?

5. What are the expected long-term community impacts of the project?

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

Financial Report (District must retain receipts of all expenditures)

7. Income Amount

1. District Grant funds received from Rotary International District 5580
2.
3.
Total Project Income

8. Expenditures (please be specific and add lines as needed)

1.
2.
3.
4.
5.
6.
7.
Total Project Expenditures

9. By signing this report, I confirm that to the best of my knowledge these District Simplified Grant funds were spent only for eligible items in accordance with Trustee-approved guidelines, and that all of the information contained herein is true and accurate. Receipts for all grant-funded expenditures have been provided to the district. I also understand that all photographs submitted in connection with this report will become the property of RI and will not be returned. I warrant that I own all rights in the photographs, including copyright, and hereby grant District 5580, RI and TRF a royalty free irrevocable license to use the photographs now or at any time in the future, throughout the world in any manner it so chooses and in any medium now known or later developed. This includes the right to modify the photograph(s) as necessary in RI’s sole discretion. This also includes, without limitation, use on or in the web sites, magazines, brochures, pamphlets, exhibitions and any other promotional materials of RI and TRF.

Certifying Signature / Date:
Type name, Rotary title, club, phone # & email address