SISTERS OF MERCY OF NORTH CAROLINA FOUNDATION, INC.

GRANT APPLICATION FOR REQUESTS $25,000 OR LESS

I. INSTRUCTIONS

Please complete the application in its entirety and supply the information exactly as requested.

• The application must be typed or printed with a computer printer in the exact format. It may not be amended or altered in any way. A handwritten copy will not be accepted.

• Place all required information that does not fit on an application page (audits, budgets, Form 990, responses to questions, etc.) behind the application and reference them to the application section and question (for example, IV.1.). Do not place the information between the pages of the application.

• All responses to individual questions are limited to a maximum of 250 words unless otherwise indicated. However, you may furnish supplementary data (e.g., news article or brochure) describing your project or program.

• The last page of the application must be signed by the organization's chief executive officer and the chairperson of the board of directors. Mechanical, copied and stamped signatures are not acceptable.

• Submit only the original grant application form and one copy of any supplementary data. Reproduced copies of the application form will not be accepted. All pages must be single-sided. Faxes are not acceptable.

  NOTE: If your organization is in the Western North Carolina region, please submit a copy of your application package, along with the original, to the Foundation’s Asheville office.

• If you have any questions about the application, please call the Foundation’s office in Charlotte at 704/366-0087. If your organization is in the Western North Carolina region, contact the Foundation’s Asheville office at 828/281-8184.

1. Date of Application: ______________________________________________

2. Name of Organization: ____________________________________________

3. Address: _______________________________________________________

4. Telephone: _____________________________________________________

5. Facsimile: ______________________________________________________

6. E-mail: ________________________________________________________

7. Chief Executive Officer: __________________________________________

8. Contact Person: _________________________________________________

9. Taxpayer Identification Number: ___________________________________

10. Please attach a copy of your organization's IRS 501(c)(3) Letter of Determination.

The letter should indicate the organization's specific classification and that it is not classified as a private foundation within the meaning of Section 509 of the IRS Code.

11. Does the organization file an IRS Form 990? Yes □ No □

If yes, please attach a copy of a current Form 990. If no, please attach a statement of explanation. (The Form 990 must be completed no later than six months following the close of the organization’s most recent fiscal year to be considered current and meet the submission requirements.)

12. Attach a statement describing your organization’s mission, goals and major program(s). Indicate the number of people served by your agency/program(s) in the previous year.

III. FINANCIAL INFORMATION

1. Please attach a copy of the most recent Audit or Compilation Report of the organization's financial statements by a public accounting firm. The Audit or Compilation Report must be completed no later than six months following the close of the organization’s most recent fiscal year to be considered current and meet the submission requirements.

As a rule, an Audit will be expected if an organization’s annual revenues and support exceed $300,000. Below that threshold, a Compilation Report is acceptable.

Note that organizations awarded a multi-year grant will be required to provide the Foundation with a copy of a current Audit or Compilation Report, whichever pertains, during the grant term as part of the annual evaluation process.

2. Has your organization received previous Sisters of Mercy of North Carolina Foundation grants?
Yes_____No_______ .

YEAR OF AWARDAMOUNT OF AWARDPURPOSE OF GRANT

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

3. Amount of Grant Requested:_____________________________________________
NOTE: The request may not exceed that which was approved at the Grant Application Summary stage.

Payment period requested: Lump Sum _ Installment _
If installment, please indicate requested timing of payment.

Year 1 $_________ Year 2 $_________ Year 3 $__________

If the grant request is for operating funds, check the box _ and indicate how grant funds would be spent on the budget form on page 5. Then proceed to Section IV.

If the request is for a specific project, check the box _ then:
- Indicate the total cost of the project for which grant funds are being requested.
$_______________
- Attach a copy of the total project budget.
- Indicate how grant funds would be spent on the budget form on page 5.

4. Budget Form
On the form below, identify which line items would be funded by this grant request. (Use this form to only indicate how grant funds would be spent)

Note: The Foundation typically does not fund items such as administrative overhead, advertising, community education, seminars, food and refreshments, incentives, handbook or manual publication, staff training, "scholarships" or direct payments to or for individuals.

Expense Items	SOM grant request
	Year 1	Year 2	Year 3
Personnel:
Salaries:	$	$	$
Benefits:	$	$	$
Contract Services:	$	$	$
Other:	$	$	$
	$	$	$
Subtotal:	$	$	$
Other Operating:
Occupancy (rent, mortgage, utilities):	$	$	$
Office Expenses (supplies, postage, duplicating, etc.):	$	$	$
Telephone:	$	$	$
Purchased Services:	$	$	$
Service Related Supplies:	$	$	$
Other:	$	$	$
	$	$	$
	$	$	$
	$	$	$
Subtotal:	$	$	$
Building Renovation and/or Equipment Purchase: (Itemize expenses according to major categories)
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
Subtotal:	$	$	$
Total	$	$	$

 

IV. PROPOSED USE OF GRANT FUNDS

1. Use of Funds. State specifically how grant funds will be spent. These items should be identified in the project or organizational budget.
2. Statement of Need. Describe the need for the project or program. Document the need with statistics, credible outside sources of information and/or other quantifiable evidence related to your service area. If this request is for organizational operating expenses, include an explanation of the need for this support.
3. Project/Program Description. Provide a description of the project or program including:

a. The number of people to be served and their relevant demographic characteristics.

b. If the population to be served is involved in the program design and delivery, what is their role?

c. How collaborative relationships are specifically involved and how they impact the success of the program, if applicable.

d. Does the program or project contribute to systemic change?



• If yes, name the "system," such as education, healthcare, social service, etc. and;
  
  
• Indicate what barriers (specific problematic policies, procedures, commonly held beliefs or common practices) that are being altered or removed within this system.
  
  
• How will accessibility and/or opportunity improve or increase within this system as a result of program or project efforts?
  
  

e. Ecumenical and/or multicultural activities.

f. Time frames for implementation.

4. Sustainment. Describe plans to sustain the organization or program.
5. Complete the Evaluation Plan on the following page. The Evaluation Plan is expected to be a working document. Should your grant request be awarded, the Foundation will ask you to report on each aspect of the Evaluation Plan in the form of an Interim or Final Report. The Evaluation Plan should not exceed one page.

1. Describe your purpose or goals for this grant request. What benefit do you intend to accomplish for the target population?

2. How many unduplicated individuals do you expect to serve annually during the grant term?

3. What are the primary activities/services that will be provided including frequency and numbers served? List as many as three. (If the request is for equipment or renovation, describe activities such as the timeframe for equipment purchase or renovation project completion.)

4. How will clients benefit specifically? What will change? Pick from the categories (knowledge, skill, behavior, condition, other) of improvement(s) or achievement(s) that you consider to be a successful annual outcome for the population to be served. Describe the outcome and indicate what percentage of those served are expected to achieve each outcome. List as many as three in the same order as the corresponding activities above.

5. What specific measurement tools, data sources and/or methods will you use to measure and verify the outcomes of the program? At what interval will measurements be taken? List each measurement tool in the same order as its corresponding outcome above. (These may include data collection or tracking, surveys, incident reports, interviews, pre- and post-testing.)

STATEMENT OF CHAIRPERSON OF THE BOARD AND CHIEF EXECUTIVE OFFICER

We declare that we are authorized to sign this application on behalf of the above organization, and that to the best of our knowledge and belief the information contained in this application is correct. We agree that we will promptly notify Sisters of Mercy of North Carolina Foundation, Inc. of any material changes in this application or the requested supporting documentation during the application process and during the grant term if a grant is awarded to our organization. We also certify that the applicant organization does not discriminate on the basis of race, religion, age, sex or national origin.