I. Name of Organization AS SHOWN ON IRS DETERMINATION LETTER (BOLD & ALL CAPS):
Executive Director (Name & Title):
Phone + Ext.:
Contact Person for Grant Proposal (Name & Title):
Phone + Ext.:
II. Mission Statement: (LIMIT to 1 Sentence ONLY – State the purpose of why the agency exists):
III. OPERATING BUDGET: Attach a current fiscal year operating budget (one-page). If you have an endowment, reserve fund or Board designated fund, please provide information on any restrictions or spending practices as a footnote in the operating budget.
IV. GRANT PROJECT: (Limit to 3 pages – see Application Submission Procedures for detailed instructions)
- ____ Maintain Current Program/Services ____ Expand Current Program/Services ____ Add New Program/Services
- Project Title:
- Executive Summary of Proposed Health Care Project/Program (LIMIT to 3-5 sentences).
- Provide the total # of West San Gabriel Valley residents served by the proposed project.
- Describe the proposed project.
- Where will the proposed project be located?
- What is the measure of success for the proposed project, i.e., define outcomes and how they will be measured.
- Provide a timeline for the proposed project.
- Provide a project budget (income sources [secured and pending] & expense items and identify what the Patron Saints Foundation funding would be used for in proposed project using the following table:
|INCOME: Provide Funder’s Name, Grant Amount & if grant is pending or secured||EXPENSES: Use BOLD TYPE to highlight the expenses that are expected to be paid with the Patron Saints Funds & Include the Project’s General Operating Expenses|
|LIST each source of pending funding (other than Patron Saints Foundation)||$||LIST Project Personnel – Hrly. Rates x # of hrs. & Professional Titles||$|
|Patron Saints Foundation Grant Request
||$||Pending||Subtotal Project Personnel||$|
|Subtotal of Pending Grants||$||LIST Project Materials/Supplies Expenses||$|
|LIST each source of secured funding||$||Subtotal Project Materials||$|
|Subtotal of Secured Grants||$||LIST Project Overhead/Admin. Expenses||$|
|Subtotal Project Overhead||$|
|TOTAL INCOME for Project||$||TOTAL EXPENSES for Project||$|
V. APPLICATION SUBMISSION PROCEDURES:
Deadline: Applications must be emailed with all PDF files on or before Midnight, March 2, 2018.
Please follow the grant application format EXACTLY. Include the question & then your response – DO NOT WRITE “SEE ATTACHED.” The grant application may not exceed 3 pages for Sections I – IV. The required attachments do not count towards the 3 page limit. The font size cannot be less than 11 point. The preferred submission method is in PDF format via email to firstname.lastname@example.org. The grant application and all documents listed below must be submitted in separate PDF files. Please contact The Patron Saints Foundation @ (626) 564-0444 if you have any questions.
- A PDF of the three-page grant application;
- A PDF of a signed Accountability Statement on the applicant’s letterhead that the funds will be utilized as stated in the grant application, as follows: This grant application from (Legal Name of Public Charity) to the Patron Saints Foundation for a grant of $______ to be used for ____________________________________ is hereby submitted; and, in the event said grant is made, either in whole or in part, the funds so granted will be used solely for the purpose specified above.
Date: _______________________ Executive Director’s Signature: ________________________________;
- A PDF of the Board of Directors List that includes their name, board title, city of residence and professional affiliation. At the bottom of the list, for the last completed fiscal year, indicate the % of board members that gave a cash donation to your agency, the total amount of their direct contributions and the total amount raised by the board (do not include direct contributions in this last figure);
- A PDF of the most recently completed grant report that you have previously submitted to the Patron Saints Foundation, if applicable. Do NOT submit the grant report of a current grant award that is still pending completion and is not closed;
- A PDF of the agency’s Financial Information:
a) PDF of the most recent audited financial statement; AND,
b) PDF of the complete copy of the most recent 990 with ALL attachments, schedules & statements;
c) If your organization does not have both of the above stated financial documents, submit the PDF documents you have and also submit a PDF of your Balance Sheet along with a PDF of your Income Statement for the most recently completed fiscal year;
- Please include a PDF of the organization’s IRS 501(c)(3) Determination Letter stating that the agency is a public, tax-exempt charity & not a private foundation; OR, (ONLY WHEN APPLICABLE) a PDF of the Face Page and the page on which the Applicant’s listing is found in the current edition of the Official National Directory of the Applicant’s Sponsoring IRS recognized Church or Public Charity, with a PDF of the IRS Group Ruling Letter to the Sponsoring Organization for its current National Directory Listing of its sponsored organizations which are covered by its Group Ruling and in which the Applicant is identified as covered by that Group Ruling;
- Provide a PDF that describes in detail, how you collected, documented and calculated the number served in Section IV., Question 4.
- For the most recently completed fiscal year, provide a PDF listing your agency’s 5 highest paid employees with their salaries plus benefits (e.g., healthcare, retirement, car allowance, etc. NO payroll taxes) in the following format:
|Job Title||Salary from W-2||Total Annual Benefits (Break out – Do not combine with salary||TOTAL COMPENSATION|