Grant – Application Grant – Application Organization Information arrowup6 Name of Organization * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Federal Tax ID# * IRS 501(c)(3) Status [NOTE: Organizations receiving funding will be required to submit their IRS determination letter.] * I attest that this organization has been designated 501(c)(3) status by the IRS and understand that a copy of the official designation will be required to accept any awarded funds Contact Information arrowup6 CEO/Exec. Director * Email * Grant Contact Person * Email * Contact Phone * Project Information arrowup6 Project Title * Amount Requested * $ Mission arrowup6 Mission Statement * File Upload: Organization Annual Report, List of Board Members, IRS Determination Letter, Brochure/Fact Sheet, or other information you would like us to consider. Drop a file here or click to upload Choose File Maximum file size: 4.19MB Project Focus Area arrowup6 Which of the following areas does your request most closely align? (Max 2) * Arts & Culture Animal Welfare Children (Supporting Children’s Needs) Economic Development Education Environment Health Human Services Project Description arrowup6 Problem Statement – Explain clearly what issue your proposed program will address within the community (Limit 500 words) * Brief description of the project (including goals, objectives, timelines, and measurable outcomes) (Limit 500 words) * Statement of need – including background data if possible, if there is an urgent need, or if the request is a time-limited opportunity (Limit 500 words) * Target population – Population served and specific connections to Portage County (Limit 500 words) * Collaboration (indicate agencies you will collaborate with and/or coordinate the delivery of services – if any) (Limit 500 words) * Evaluation Plan – How will you determine your short/long-term success as a result of project? (Limit 500 words) * Optional : Other supporting information – Is the request innovative or novel? What is the sustainability of the project? Note: You may embed hyperlinks to provide additional information (Limit 500 words) Budget of Total Amount Requested arrowup6 Item (1 – 5) Unit Cost $ Cost $ Unit Cost $ Cost $ Unit Cost $ Cost $ Unit Cost $ Cost $ Unit Cost $ Cost $ Total Request (Must Match Total Amount Requested Above) * $ Optional : Other Budget Information – Other sources of income or other related budget items (Limit 500 words) Optional: More Detailed Budget Spreadsheet or Budgetary Information Drop a file here or click to upload Choose File Maximum file size: 4.19MB Supplemental Materials arrowup6 File Upload Drop a file here or click to upload Choose File Maximum file size: 4.19MB Submission Signature signature keyboard Clear Name Printed * Submission Date * * By submitting this electronic application, I/we certify that I/we reviewed the information and to the best of my/our knowledge it is accurate. Submit If you are human, leave this field blank. Δ