Duluth Superior Area Community Foundation Grant Application Duluth Superior Area Community Foundation Grant Application Zeitgeist Arts Building 222 East Superior St, Ste 302 Duluth, MN 55802 This application is based on the Minnesota Common Grant Application, but does contain some modifications for an online format. INSTRUCTIONS Step 1: Complete the online application form. Please complete all sections of the application and limit your answers to the space provided. After completing the application, please save the document using the ‘save as’ feature and include your organization’s name in the document name. This will be your copy of the application. Move to Step 2. This form is designed with Adobe Reader. You perhaps can open and type into it with your web browser, HOWEVER, the save function may not work correctly if you do so. It is therefore important to use ADOBE READER to create a document which is fill-able, save-able and return-able. Application Sections •Grant Application Information Summary •Organizational Information •Proposal Information •Evaluation Information •Organizational Budget •Organization Funders •Project Budget •Project Funders •List of Board of Directors •Self Certification Step 2: Submit Attachments The following items must be sent for the grant application to be considered complete. If possible, please scan the original documents and send as an attachment with the application to grantsinfo@dsacommunityfoundation.com. •Cover Letter (optional) If desired, please include the cover letter with the completed application. •Audited financial statement If current year audit is not available, send the most recent audit you have, and the unaudited year end financial statement of income and expenses for the most recently completed fiscal year. Send the audit when it is available. An audit is highly preferred. If your organization isn't audited, an IRS Form 990 for the most recently completed fiscal year is required. •Copy of most recent IRS Determination Letter indicating 501(c)(3) status. Step 3: If applying using a Fiscal Agent: You will need a Fiscal Agent in order to apply for a grant from the Community Foundation, if your organization has not yet secured a 501(c)(3) determination letter from the Internal Revenue Service. The following information is needed from your Fiscal Agent: If possible, please scan the original documents and send as an attachment to grantsinfo@dsacommunityfoundation.com •Acknowledgment in writing from the Fiscal Agent to accept funds on your organization's behalf for your project. •A copy of your Fiscal Agent's 501(c)(3) IRS ruling. •A list of your Fiscal Agent's Board of Directors. •A copy of your Fiscal Agent's most recent independent audit. Questions or concerns? Please contact us at 218.726.0232 or grantsinfo@dsacommunityfoundation.com Duluth Superior Community Foundation Grant Application One finalArea reminder: please be sure to use Adobe Reader to complete this form! Download the form to your desktop; open Reader; go to File / Open in the top dropdown menu; select this form; click return GRANT APPLICATION INFORMATION SUMMARY Name of Organization Legal name, if different Address Line 1 Address Line 2 City State Zip Website Employer Identification Number (EIN) Phone Fax Name of top paid staff or Board Chair Title Phone Email Contact person for this application Phone Title Email Is your organization an IRS 501(c)(3) not for profit, public entity or unit of government? Yes No If no, see page one for details on using fiscal agents and list the name and address of fiscal agent: Ficsal Agent Name Address Line 1 Address Line 2 City State Ficsal Agent's EIN Zip Proposal Information Project/Program Name Geographic Area Served Funds are being requested for (select one) General Operating Capital Support Population Served Start Up Costs Technical Assistance Other (please explain) Project Dates Start (MM/DD/YY) End (MM/DD/YY) Fiscal Year End Budget Community Foundation Fund Applying To Amount Requested Total Project Budget Can we share this application for funding with a Donor Advisor? Total Annual Organization Budget for the year requesting funds Yes No Project/Program Support ORGANIZATIONAL Duluth SuperiorINFORMATION Area Community Foundation Grant Application Please provide a brief summary of the organization history, mission/goals and current programs or activities, including any service statistics and strengths or accomplishments. Please indicate the structure of your organization, number of board members, full-time paid staff, part-time paid staff and volunteers. Duluth Community Foundation Grant What is yourSuperior organization’sArea relationship with other organizations working with similar Application missions? What is your organization’s role relative to these organizations? PROJECT/PROGRAM INFORMATION Please provide a detailed description of the proposed project and the specific activities for which you are seeking funding. Duluth Superior Area Community Foundation PROJECT/PROGRAM INFORMATION (continued) Grant Application Please describe the opportunity, challenges, issues/need within the community that your proposal addresses. Describe your overall goal(s) regarding the situation described above; what are the objectives or ways in which you will meet those goal(s)? Duluth Area Community Grant How will theSuperior proposed activities benefit the community,Foundation being as clear as you can aboutApplication the impact you expect to have? Briefly describe how this focus was determined and who was involved in that decision-making process. Who will carry out the activities in the proposed project? What is the timeframe in which this will take place? Duluth Superior Community Foundation Grant Application How does the project fit theArea fund's guidelines/strategy? What are the long-term funding strategies (if applicable) for sustaining this effort? EVALUATION INFORMATION Duluth Superior Area Community Foundation Grant Application Describe your criteria for the project's success, how you will measure the changes, and use the evaluation results? How will you measure the effectiveness of the project? Who will evaluate the effectiveness the project? Duluth Superior AreaofCommunity Foundation Grant Application ADDITIONAL INFORMATION Please use this space to provide additional information or continue any answers that do not fit in the spaces provided above. Duluth Superior Area Community Foundation Grant Application ORGANIZATIONAL BUDGET Provide budget information for the fiscal year for which funds are to be used. Please check this box if you would prefer to submit an organizational budget that contains this information in a different format. Send organizational budget to grantsinfo@dsacommunityfoundation.com. SUPPORT INCOME Source Amount Government grants Foundations Corporations United Way/Other Campaigns Individual Contributions Fundraising Events & Products Membership Income In-kind Support Investment Income REVENUE INCOME Government Contracts Source Amount Item Amount Earned Income Other (please specify) Total Income EXPENSES Salaries & Wages Insurance/benefits/other taxes Consultants & Professional Fees Travel Equipment Supplies Printing & Copying Telephone & Fax Postage & Delivery Rent & Utilities In-kind Expenses Depreciation Other (please specify) Total Expenses Difference (Income less Expense) Duluth Superior Area Community Foundation Grant Application ORGANIZATION FUNDERS (government, foundation, corporate) Prior Year Funder's Name Amount Current Year Funder's Name *TBA = To Be Approached Secured / Pending / TBA* Amount Duluth Superior Area Community Foundation Grant Application PROJECT BUDGET Please check this box if you would prefer to submit a project budget that contains this information in a different format. Send project budget to grantsinfo@dsacommunityfoundation.com. SUPPORT INCOME Source Secured/Pending/TBA* Amount Government grants Foundations Corporations United Way/Other Individual Contributions Fundraising Events/Products Membership Income In-kind Support Investment Income REVENUE INCOME Government Contracts Earned Income Other (please specify) Total Project Income EXPENSES Salaries & Wages (breakdown by individual position, indicate full- or part-time.) Item % FTE Subtotal Insurance/benefits/other taxes Consultants & Professional Fees Travel Equipment Supplies Printing & Copying Telephone & Fax Postage & Delivery Rent & Utilities In-kind Expenses Depreciation Other (please specify) Total Project Expenses Difference (Income less Expense) Amount Duluth Superior Area Community Foundation Grant Application LIST OF PROJECT FUNDERS Prior Year Funder's Name Amount Current Year Funder's Name *TBA = To Be Approached Secured / Pending / TBA* Amount DuluthOFSuperior Area BOARD DIRECTORS Community Foundation Grant Application Please check this box if you would prefer to submit your board of directors list in a different format. Employer/Former Employer (affiliation) Job Title Name Board Title 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Duluth Superior Area Community Foundation Grant Application SELF-CERTIFICATION CHECKLIST All materials must be received by 5:00pm on the application deadline. Please indicate how the materials will be submitted. Online Form Emailed Mailed On File N/A 1. Cover Letter (optional) 2. Grant Application Information 3. Organizational Information 4. Proposal Information 5. Evaluation Information 6. Organization Budget 7. Organization Funders 8. Project Budget 9. Project Funders 10. List of Board of Directors 11. Audited financial statement or IRS Form 990 12. Copy of federal IRS Determination Letter indicating 501(c) (3) tax exempt status If applying using a fiscal agent: Emailed Mailed 1. A written agreement from the Fiscal Agent to accept funds on your organization’s behalf for your project. 2. A copy of your Fiscal Agent’s 501(c)(3) IRS ruling 3. A list of your Fiscal Agent’s Board of Directors 4. A copy of your Fiscal Agent’s most recent independent audit CERTIFICATION STATEMENT By checking this box, I certify that all the information in this application is true to the best of my knowledge. In addition, I certify that I will submit a complete application, fulfilling all of the items on the self-certification checklist on the first page of the application. I also acknowledge that the organization’s top paid staff member or Board Chair is aware of the submission of this grant application to the Duluth Superior Area Community Foundation. Name Title