Grant Report Form
Organization Information
Organization Name
Organization Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Phone
Please enter a valid phone number.
Contact Person
First Name
Last Name
Contact Phone Number (if different than above)
Please enter a valid phone number.
Project / Program Information
Project / Program Name:
Purpose of Grant (one sentence)
Overall Project / Program Start Date
-
Month
-
Day
Year
Date
Overall Project / Program End Date
-
Month
-
Day
Year
Date
Amount of Grant Awarded:
Have there been any changes to your organization's IRS 501(c)(3) not-for-profit status since your request for this grant?
No
Yes
If yes, please explain
Select One:
This is an interim report
This is a final report
If Interim Report, what dates are covered herein?
Signature of Executive Director or President
Project Information
Brief Description of Project
Results
Outcomes: please describe results in outcome-based terms.
For example, what difference did this grant make in your community and for the populations you are serving? Were there any unexpected outcomes?
Did your project have any variances from the original plan? In what ways did it vary? Describe how and why.
Describe collaborative efforts that resulted from this grant funding.
Describe your future plans for this project.
What barriers did you face in implementing your project (if any)? If this was a regional grant, were these barriers any more or less significant in any one area?
Were you able to leverage more funds because of this grant from HSC?
Yes
No
If yes, please describe here.
If this was a regional grant, how did the results affect the region as a whole? Did one area benefit more than another? Why?
Financial Information
Total Project Cost
Budget Changes
Indicate how the grant funds were spent (please provide detailed expenses and income for the project)
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Future funding plans, if applicable
Public Relations
Please attach any printed material relating to the funded project / program: press or news items, brochures, letters of support, photographs, etc.
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