fy2015 16 grant application submission deadline: …...total operating budget. year: _____ budget:...
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Greening and Growing Middlesex County for 80 Years
FY2015‐16 GRANT APPLICATION
Submission Deadline: November мф, 201р, 12:00 Noon – Handwritten Submissions Will Not Be Accepted
Project Title: _________________________________________________________________________________________________
Location: ________________________________________________________________________________________________
Project Coordinator (include title): ____________________________________________________________________________
Phone: ________________________________________ Email: ____________________________________________________
Applicant Organization: ________________________________________________________________________________________
Authorized Agent: ______________________________________ Website: __________________________________________
Address: ______________________________________________ City, State, Zip: _____________________________________
Phone: _________________ Fax: ______________________ Email: _____________________________________________
Co‐Applicant Organization: _____________________________________________________________________________________
Authorized Agent: ______________________________________ Website: __________________________________________
Address: ______________________________________________ City, State, Zip: _____________________________________
Phone: _________________ Fax: ______________________ Email: _____________________________________________
Request: Dollar Amount Requested: $_________________________ Total Project Cost: $_________________________________ single year project 2‐year project
Synopsis: Describe the project and how it meets the purpose of the grant. The response is limited to no more than 3 sentences and 400 characters (including spaces).
Estimated Number of People to Be Served by the Project: ______ Age Range of People to Be Served by the Project: _________
Existing/Continuing Project/Internship: Yes No New Project/Internship: Yes No
Geographic Area Served by the Project. Check all that directly apply.
All Middlesex County Chester Clinton Cromwell Deep River
CT River Corridor Durham East Haddam East Hampton Essex
Long Island Sound Haddam Killingworth Middlefield Middletown
Old Saybrook Portland Westbrook
Geographic Area Where Organization is located. Check all that directly apply.
All Middlesex County Chester Clinton Cromwell Deep River
CT River Corridor Durham East Haddam East Hampton Essex
Other: Haddam Killingworth Middlefield Middletown
____________________ Old Saybrook Portland Westbrook
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Organization Information:
Applicant:
501(c)3 Organization yes no Government Entity yes no School yes no
Federal ID#: ___________________ CT tax exempt #: ____________________ Year Organized: _________________
Date most recent IRS Form 990 was filed (Non‐Profits). Year of Return: ________________ Date Filed: _______________
Total Operating Budget. Year: ____________________ Budget: $_________________________________________
Please attach a one page summary of the organization’s current operating budget and (for Non‐Profits) a copy of the first two pages of the last 990 filing.
Briefly state the applicant organization's Mission. (Response limited to 400 characters with spaces.)
Briefly describe the applicant organization's background/history. (Response limited to 500 characters with spaces.)
Co‐Applicant:
Federal ID#: ___________________ CT tax exempt #: ____________________ Year Organized: _________________
501(c)3 Organization yes no Government Entity yes no School yes no
Date most recent IRS Form 990 was filed. Year of Return: ___________________ Date Filed: _____________________
Total Operating Budget. Year: ____________________ Budget: $_________________________________________
Please attach a one page summary of the organization’s current operating budget and (for Non‐Profits) a copy of the first two pages of the last 990 filing.
FY2015‐16 Grant Application Page 3 of 6
Project Financial Information. Please complete the summary forms below. If necessary, the forms may be replicated on a separate page. Note: If grant is awarded, funding MUST be applied to the items/activities described below. Substitutions are not permitted unless prior approval is obtained.
Program Expense Item Description Rockfall Grant
Request In‐Kind Matching $ Total Amount
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
Project Totals $ $ $ $
Please provide information below for any income sources that are included as matching dollars above.
Matching $ Explanation Budget Amount Status
Other Grants (please indicate if grant monies are committed, pending or to be
requested):
$
$
$
$
$
$
Other income sources (including regular operating budget): $
$
$
$
$
$
$
$
$
Project Total $
FY2015‐16 Grant Application Page 4 of 6
Grant Program / Project Information (bulleted responses accepted):
1. State the environmental education goals to be addressed by this project. (Response limited to 750 characters with spaces.)
2. Describe the measurable outcomes to be achieved by this project. (Response limited to 1,000 characters with spaces.)
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3. Describe the project activities and timeline, including specifically the activities funded by this grant. (Response limited to 2,500 characters with spaces.)
FY2015‐16 Grant Application Page 6 of 6
4. Describe the evaluation methods that will be used to determine whether the objectives of the project have been met. For multi‐year projects, include a plan for interim evaluations. (Response limited to 750 characters with spaces.)
5. Describe how Rockfall’s participation in this project will be recognized. (Response limited to 500 characters with spaces.)
Application submitted by: Organization’s Authorized Agent: _______________________________________________ _______________________________________________ (Signature) (Date) (Signature) (Date)
Print Name: ____________________________________ Co‐Applicant Organization’s Authorized Agent: _______________________________________________ (Signature) (Date)
Applications must be received at the Rockfall Foundation, 27 Washington Street, Middletown, CT 06457 by 12:00 noon on Thursday, November мф, 201р. Applications should be submitted electronically to [email protected] received after the deadline will not be considered.
If you have any questions please contact Tony Marino at the above email address or at 860.347.0340