Common Grant Application for The Clifford Willard Gaylord Foundation

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COMMON GRANT APPLICATION COVER SHEET

Grant Requestor Email*

A copy of the form will be emailed to the address.

Grantmaker to whom this application is submitted:*

Application date:*

Organization’s legal name: (as shown on IRS Letter of Determination)*

Doing business as: (if different from legal name)

EIN #:*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Org. Telephone #:*

Org. Fax #:

Org. Website:

Org. Email Address:*

Executive Director: (or top executive)

Executive Director Phone#:

Executive Director Email Address:

Main contact(s) for this proposal:

Main contact(s) Phone#:

Main contact(s) Email Address:

Board President:

Board President Phone#:

Board President Email Address:

Organization’s mission statement:

Type of request (check one):

Capacity Building Support

Capital Campaign

General Operating Support

Project/Program Support

Other

Note: not all funders support each type of request. Check with individual grantmaker.

if checked Project/Program Support

New Project

Existing Project

Expansion of Existing Project

If checked other explain

Project/campaign name: (if general operating please indicate)

Proposal summary: In 100 words or less summarize the purpose of this request.

Funding period requested:

(be specific)

Amount requested:

Total project budget for this period:

(not required if general operating request)

Organizational annual budget:

Organization fiscal year:

Geographic area(s) served: (include specific counties)

Does your organization receive funding from a giving federation? Please list all that apply. (e.g., United Way, Arts and Education Council, Jewish Federation)

Agreement

I certify, to the best of my knowledge, that all information included in this proposal is correct. The tax exempt status of this organization is still in effect. If a grant is awarded to this organization, then the proceeds of that grant will not be distributed or used to benefit any organization or individual supporting or engaged in unlawful activities. In compliance with the USA Patriot Act and other counterterrorism laws, I certify that all funds received from this funder will be used in compliance with all applicable anti-terrorist financing and asset control laws, statutes, and executive orders.

Signature & Title of Authorized Representative (e.g. Executive Director)

Date

1. Brief summary of organization’s history and brief description of previous year’s accomplishments.

2. Purpose of this funding request. Please describe:

a. Community/client needs or problems that will be addressed by this project AND 3-5 strengths of the community/clients your organization serves. (See User Guide, Section C, Questions 5 & 6 for more information). b. The target population, number of individuals, and geographic area that will benefit from this proposal. c. What your organization hopes to accomplish (outputs and/or outcomes). d. How your organization intends to accomplish the above.

3. If applicable: Names and brief description of roles of partners on this project.

4. List any internal or external efforts your organization is currently undertaking to incorporate diversity, equity, and/or inclusion (DEI) into its policies and practices. Are there DEI initiatives your organization hopes to undertake?

• Answers to this question will provide a valuable perspective on our potential grantees’ capacity to address diversity, equity, and inclusion issues. See the User Guide, Section B, Question 3 for more information and example.

Required Attachments

Note: Please attach documents last. Upload documents when your ready to submit the application. If you save and continue later, the attachments will disappear, and you will have to reupload them. Developers are working on fix, but will be awhile.

1. Project budget using the CGA budget template provided. (NOTE: check both tabs of the spreadsheet).

Max. file size: 128 MB.

2. Organization’s annual budget.

Individual grantmakers may choose to request additional attachments. Please check with the individual grantmaker.

Max. file size: 128 MB.

3. IRS Letter of Determination.

Max. file size: 128 MB.

If not a 501(c)(3) nonprofit, then who is the fiscal agent?

(Attach a copy of the written agreement from fiscal agent plus fiscal agent’s contact information and EIN.)

Max. file size: 128 MB.

Organization’s tax exempt status/IRS designation (e.g., 501(c)(3), 501(c)(9), etc.)

(Attach a copy of the IRS Letter of Determination- NOTE- this is not the state sales and use tax exemption certificate. If there has been a name change provide copies of the amended state certificate of incorporation and amended IRS Letter of Determination.)

Max. file size: 128 MB.

Phone

This field is for validation purposes and should be left unchanged.