Community Impact Fund Grant Application
Organization Name
*
Enter Legal Name of the Organization and/or DBA
Contact Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Website URL
(If applicable)
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
501c3 Tax Exempt Status
*
Yes
No
Upload copy of 501c3 letter
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Organizational Information
Mission Statement and History
250 Word Limit
0/250
Total Organization Budget
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Budget should reflect the total percentage of program, operation, and fundraising expenses
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Upload Most Recent 990
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Number of people served per year
Programming Information
Program Name
*
Name of the program for which you are requesting funding
Geographic Area Served
Please indicate cities and states
Number of people served in this specific program
Program-Specific Budget
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Include the program specific budget including a descriptive justification for each expense and the salary allocation (FTE) of each staff to each program including volunteer hours
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Total Funds Requested
Problem Statement: What issues or concerns does this program target?
How will you use the funds to address the issues or concerns?
Benchmark #1: How will the success of the program be measured?
Example: 200 students will be trained to XXX.
Benchmark #2: How will the success of the program be measured?
Example: 100 Students will secure employment through our employment placement service
Benchmark #3: How will the success of the program be measured?
Example: 20 Students who have graduated the program will sign up as mentors
Demographics
Racial/Ethnic Population Served
Socio-Economic Demographic Served
Example: Disadvantaged youth, Alzheimer's patients, caregivers from underserved, low income communities
Male/Female/Transgender population served by percentage
If the gender gap is larger than 50% please explain the reason. If applicable explain what you are doing to bridge the gender gap
Comments
Please verify that you are human
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