Name & address of applicant organization:	Is the name at the left the same as it appears on the IRS 501(c)(3) Letter of Determination? __yes __no If not, explain:
Telephone Number: Fax Number: E-mail:	For current fiscal year: Organization’s total budgeted revenue: Organization’s total budgeted expenses: Fiscal year: __________ to __________
Chief Executive Name and Title:   9-digit Federal Employer ID #: Year organization incorporated:	Revenue Sources: ___ % government (city,county, state, federal) ___ % United Way ___ % membership	___ % fees ___ % grants ___ % investment income ___ % fund raising (e.g. events, gifts, bequests, etc.)

Information for This Request

Name of this program or project:   Program/project contact person: Name: Phone #: Total cost of this effort: Amount requested from this funder:   Type: __Capital __ Construction __ Renovation __ Equipment __Endowment __Program/Project __General Support __Other (describe)   Date funds needed by: Date by which funds will be spent:

List other potential and actual sources of support - put an "*" by those committed, noting any matching fund requirements. Amount         Funder             List major funders of program/project for past two years if applicable: Amount         Funder

Inputs ($’s, staff, volunteers, materials & other resources required)	Activities (What the program does with the inputs to achieve its outcomes)	Projected Outcomes (Effects on knowledge, attitudes, skills, behavior, condition or status during or after the program/project)
Quantify inputs wherever possible (e.g. "2.5 FTE social workers," "270 volunteer hours")	Activities should be quantified (e.g. 2 support groups/10 moms ea./2 hrs/wk for 4 mos.)	Shorter-term Outcomes  put a "*" next to those you will measure	Longer-term Outcomes  put a "*" next to those you will measure

(Add additional pages if needed.)

(Please include the following. We strongly encourage you to limit the total length of the rationale to 4 pages or less.)

1. Need/demand (present in bulleted format, and where possible, include local statistics, community priorities, etc)
1. Summarize the need for your planned work.
2. Summarize customer demand for this work.
2. Outcomes

For each outcome you will track, as identified in your logic model, indicate how you will know if you succeed in achieving it, using the following format.

 

Outcomes	Indicators/Measures (What will you measure to know if you reach your outcomes?)	Targets/Performance Standards/Projected levels of success/What will tell you that you have achieved your outcomes?	By when will targets be achieved?

 

3. Activities (use bullets or a chart where possible)

Why do you believe the activities listed in your logic model reduce or eliminate the need described in item A on this page?

4. Organizational capacity to undertake project
1. What is your organization’s mission, and how does this project relate to it?
2. Summarize similar program accomplishments in the past, including the extent to which your outcomes were reached (use bullets or a chart where possible).
5. Links with other agencies
1. If this is a collaborative effort, complete the following:

 

Collaborating organizations	Contact person	Phone number	Role(s) of partners

2. Do you know of other groups doing similar or related work? If so, how does your work differ from or complement theirs?
6. What is the future of the program or project beyond  the grant period?
1. In terms of programming, summarize what is envisioned.
2. If it is to continue beyond the grant period, how will you support this project?
7. In no more than ½ page, say anything else you want to about this request.