Southwest Minnesota Arts & Humanities Council

114 North 3rd Street, Marshall, MN 56258

Cultural Bank Application Form

July 01, 2016 – June 30, 2017

Submit a typed and signed original. Keep a copy for your records. Double-check your math.

APPLICANT INFORMATION

Name of Member or Organization
Address / City / Zip
Person Completing Application / TelephoneNumber
Address / City / Zip
Email

PROJECT INFORMATION

Name of Program
Date(s) of Program
Time & Place of Program
Anticipate Audience Size / Anticipated Number of Participants
Describe the Program
What action is your organization taking to ensure the financial success of this project?

Program Budget: Clearly identify each item. Anticipated income must equal or exceed anticipated expense.

Anticipated Expense

1. Salaries/Artists Fees
$
$
2. Expendable Supplies & Materials
$
$
3. Publicity (printing, ads)
$
$
4. Transportation & Subsistence
$
$
5. Communications (phone, postage)
$
$
6. Rental & Other
$
$
7. TOTAL / $
8. Cultural Bank Support Request
(may not exceed 1/3 of cost or $400) / $

Anticipated Income

1. Cash in treasury or budgeted
for the Project / $
$
2. Ticket Sales / $
Ticket Prices
# Tickets to be sold
3. Participation Fees (if applicable) / $
Amount of Fee
# of Participants
4. Other Earned Income / $
(ad sales, concessions, etc)
Other (describe)
$
$
$
6. TOTAL / $
(must equal or exceed total expenses)
7. Advance for Pre-Program Expenses(if necessary) / $

Agreement: I certify that the above information is true to the best of my knowledge and I pledge our organization to meet the terms of the Cultural Bank program.

Signature of Authorizing Official / ______ / Date / ______
Total Org. Expenses - most recently completed Fiscal Year (FY): / $ / FY

RAC GRANT DATA COLLECTION FORM

TO THE APPLICANT: This form is used to gather information about grant applicants to the Minnesota Regional Arts Councils (RACs). The data is maintained by the Minnesota State Arts Board in cooperation with the RACs, and may be distributed to others in accordance with the Minnesota Data Practices Act. Complete information is necessary to ensure the reliability of our data. Note: If you are using a fiscal agent, please fill out this first page as it pertains to the arts organization conducting the activity, not the fiscal agent.

1.APPLICANT INFORMATION

Date
Legal name of organization or individual
Professional or other name
Address
City / State / Zipcode
Day phone
E-mail address
Contact person name and title
County / MN House district / U.S. Congressional district
Fiscal agent name (if applicable)

2.SPECIAL CHARACTERISTICS:

For individuals applying (optional)
Select any combination that applies describing your racial/ ethnic characteristics. This information is not made public.
For organizations applying
Select the one code that best represents 50% or more of your staff or board or membership / American Indian/Alaska Native (N)
Asian (A)
Native Hawaiian/Pacific Islander (P)
Black/African American (B)
Hispanic/Latino (H)
White (W)
Other / For individuals, mark these items if they apply
(optional)
Disability (I)
Older Adult - 60+ (S)
Veteran (V)

3.STATUS:

Select the one code which best
describe the applicant’s legal
status / 01Individual
02Organization-Nonprofit
03Organization-Profit / 04Government-Federal
05Government-State (includes public schools)
06Government-Regional / 07Government-County
08Government-Municipal
09Government-Tribal
99None of the Above

4.INSTITUTION:

Select the one code which best
describe the applicant
/ 01Individual artist
02Individual non-artist
03Performing Group
04Performing Group-College/University
05Performing Group-Community
06Performing Group-Youth
07Performance Facility
08Museum (Art)
09Museum (Other)
10Gallery/Exhibition space
11Cinema
12Independent Press
13Literary Magazine
14Fair/Festival
15Arts Center
16Arts Council/Agency
17Arts Service Organization / 18Union/Professional Association
19School-District
20School-Parent/Teacher Assn
21School-Elementary
22School-Middle
23School-Secondary
24School-Vocational or Technical
25School-Other (incl Community Ed)
26College/University
27Library
28Historical Society/ Commission
29 Humanities Council/Agency
30Foundation
31Corporation/ Business
32Community Service Organization
33Correctional Facility
34Health Care Facility
35Religious Organization / 36Seniors Center
37Parks & Recreation
38Government-Executive
39Government-Judicial
40Government-Legis (House)
41Government-Legis (Senate)
42Media-Periodical
43Media-Daily Newspaper
44Media-Weekly Newspaper
45Media-Radio
46Media-Television
47Cultural Series Organization
48School of the Arts
49Arts Camp/ Institute
50Social Service Organization
51 Child Care Provider
99 None of the Above

2010 DataCollection Form.Doc 4/2009

Legal name of organization or individual

5.DISCIPLINE:

Select one code whichbest describes theapplicant’s primary areaof interest in the art
(e.g. ballet 01A)
/ 01 Dance—general
01Aballet
01Bethnic/jazz/
folk-inspired
01Cmodern
02 Music—general
02Aband
02Bchamber
02Cchoral
02D new-experimental,
electronic
02Eethnic/folk-inspired
02Fjazz
02Gpopular
02Hsolo/recital
02Iorchestral
03 Opera/Musical Theater—general
03Aopera
03Bmusical theater
04 Theater—general
04Atheater, in general
04Bmime
04Cpuppetry
04Dtheater for young people
04Estorytelling
10Cplaywriting/scriptwriting / 05 Visual Arts —general
05Aexperimental
05Bgraphics (include drawing, cartooning,
printmaking, book arts)
05Dpainting
05Fsculpture
06 Design Arts —general
06Aarchitecture
06Bfashion
06Dindustrial
06Einterior
06Flandscape architecture
06Gurban/ metropolitan
07 Crafts—general
07Aclay (includes ceramics)
07Bfiber (includes basketry)
07Cglass
07Dleather
07Emetal
07Fpaper
07Gplastic
07Hwood
07Imixed media
08 Photography (include holography) / 09 Media Arts —general
09Afilm
09Baudio
09Cvideo
09Dtechnology/
experimental
09Escreenwriting
10 Literature—general
10Afiction
10Bnon-fiction
10Cplaywriting/ scriptwriting
10Dpoetry
11 Interdisciplinary (include collaborations & performance art)
12 Folklife/Traditional Arts, in general
12ADance
12BMusic
12CCrafts and
visual arts
12DOral traditions
13 Humanities
14 Multi-disciplinary
15 Non-arts/non-humanities

PROJECT ACTIVITY

6. Adult Artists Participating Record the number of adult artists expected to be directly involved in providing art or artistic services for these grant activities.

7. Adult Audience Benefiting Record the number of adult audience expected to benefit directly from these grant activities (excluding employees, paid performers, artists participating, children/youth, and broadcast figures). Do not double-count repeat attendees.

8. Children/Youth Benefiting Record the number of children and youth under the age of 18 expected to participate in and/or benefit directly from these grant activities, or were included in the audience (excluding broadcast figures). Do not double-count repeat attendees.

9. Project Discipline Usingthe same discipline coding listed above, select one category which best describes the grant activity.

10. For organizations applying, total organization expenses for most recently completed fiscal year: $ _ FY _

TO BE COMPLETED BY REGIONAL ARTS COUNCIL STAFF ONLY

Total Project Revenue $
(cash only-include grant request) / Total Project Cost (cash only) $ / In-Kind Contributions$
FISCAL YEAR
RAC
APPLICATION # / GRANT REQUEST $
RECOMMENDED $
AWARDED $ / SOURCE OF FUNDS
State General Fund $ ACHF Arts & Arts Access $
Federal $ ACHF Arts Education $
Other $ ACHF Arts & Cultural Herit $
GRANT PROGRAM
Production Assistance
Sponsorship Activity / General Operating Support
Organization Arts Project
Organizational Management Support / Arts in Education School Residency
Arts Scholarship
Individual Artist
Other

APPLICATION WITHDRAWN APPLICATION INELIGIBLE

Reason for ineligibility or withdrawn application
Comments

ALL INFORMATION ON THIS FORM HAS BEEN REVIEWED AND IS COMPLETE AND CORRECT.