Jackson Emergency Response Application

EMERGENCY SUPPORT FOR JACKSON, MISSISSIPPI FUNDING REQUEST

Partnering to Reimagine the Response to HIV/AIDS in the South
ABOUT CHANGE THE PATTERN.

The National AIDS Memorial is partnering with Southern AIDS Coalition to bring sections of the AIDS Memorial Quilt to communities throughout the Southern U.S to highlight and honor Black and Brown lives lost to HIV and AIDS.

Change the Pattern is a new initiative created to reimagine the response to the epidemic in the region. The program brings an opportunity for learning and action through immersive Quilt displays, educational programming, advocacy, quilt-making, and community grants in twelve Southern states: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee and Texas.

ABOUT THIS FUNDING OPPORTUNITY.

This funding opportunity, supported through a $100,000 grant from the National AIDS Memorial in partnership with Southern AIDS Coalition and Gilead Sciences, will provide organizations in Mississippi with rapid response funds ranging from $5,000-$10,000 to support immediate needs of communities impacted by the Jackson water crisis. Funding will support community-based HIV/AIDS organizations in their efforts to serve constituents impacted by the current water crisis.

FUNDING REQUIREMENTS.
- Please be advised that this funding opportunity is only available to organizations in Mississippi with 501(c)(3) tax status, or a fiscal sponsor with said tax status.
- Funded organizations should be located in Jackson, or providing services to Jackson and surrounding communities impacted by the water crisis.
- Organizations funded must have a mission or focus on serving those living with HIV, impacted by HIV or otherwise work at the intersections of HIV, health, and justice.
- Use of funds may include, but is not limited to:
  - Purchasing water, food, supplies, and materials for distribution to impacted communities
  - Costs of transporting items to impacted communities
  - Cost of transporting clients to obtain necessary items
FUNDING AVAILABILITY. This fund will award up to $100,000 to organizations to address immediate community needs

SAVING YOUR APPLICATION: If at any time you'd like to leave this form and save it in progress, please click on the next button and exit your browser. To resume your submission at a later time, return to the form from the link contained in your registration email. (YOUR BROWSER MUST BE ENABLED TO ACCEPT COOKIES. DATA IS SAVED LOCALLY IN YOUR BROWSER UNITL SUBMITTED)

Technical Assistance. Should you have technical questions regarding the online submission process, please contact: ctp@southernaidscoalition.org

Is your organization Mississippi-based and providing support and services in direct response to the Jackson water crisis?*

YesNo
I'm sorry, only Mississippi-based organizations providing services in direct response to the water crisis are eligible for this opportunity. Please click on the link below to learn about other opportunities to engage with Change the Pattern. Click Here
SAVING YOUR APPLICATION: If at any time you'd like to leave this form and save it in progress, please click on the next button and exit your browser. To resume your submission at a later time, return to the form from the link contained in your registration email. (YOUR BROWSER MUST BE ENABLED TO ACCEPT COOKIES. DATA IS SAVED LOCALLY IN YOUR BROWSER UNITL SUBMITTED)

Technical Assistance. Should you have technical questions regarding the online submission process, please contact: ctp@southernaidscoalition.org

Fiscal Sponsor Information
Fiscal Sponsor Organization
Fiscal Sponsor Primary Contact

First NameLast Name
Fiscal Sponsor Email
example@example.com
Fiscal Sponsor Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fiscal Sponsor Website
Upload Fiscal Sponsor IRS Determination Letter:

Browse Files

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Upload Fiscal Sponsor Most Recently Filed 990:

Browse Files

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Contact Information

CTP Funding Request
Primary Contact*

First NameLast Name
Pronouns
Contact Title*
Phone Number*

Area CodePhone Number
E-mail*
Address (if different from above)

Street Address

Street Address Line 2

CityState

Zip Code
Chief Executive Information (if different from Primary Contact)
Chief Executive Full Name

First NameLast Name
Pronouns
Title
Phone Number

Area CodePhone Number
E-mail
SAVING YOUR APPLICATION: If at any time you'd like to leave this form and save it in progress, please click on the next button and exit your browser. To resume your submission at a later time, return to the form from the link contained in your registration email. (YOUR BROWSER MUST BE ENABLED TO ACCEPT COOKIES. DATA IS SAVED LOCALLY IN YOUR BROWSER UNITL SUBMITTED)

Technical Assistance. Should you have technical questions regarding the online submission process, please contact: ctp@southernaidscoalition.org

Financial Information

CTP Funding Request
Current Operating Budget $ (Organization)*
Fiscal Year Starting *
Fiscal Year Ending *
Fiscal Sponsor Information

**Complete Only If Applicable**
Fiscal Sponsor Organization
Contact Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SAVING YOUR APPLICATION: If at any time you'd like to leave this form and save it in progress, please click on the next button and exit your browser. To resume your submission at a later time, return to the form from the link contained in your registration email. (YOUR BROWSER MUST BE ENABLED TO ACCEPT COOKIES. DATA IS SAVED LOCALLY IN YOUR BROWSER UNITL SUBMITTED)

Technical Assistance. Should you have technical questions regarding the online submission process, please contact: ctp@southernaidscoalition.org
Rapid Response Activities

CTP Funding Request
Will funds be used to do any of the following (select all that apply)?*

Transportation costs for staff/volunteersTransportation for community membersBottled waterFood/NutritionCleaning SuppliesOther
Amount of Funding Request ($5,000-$10,000)
Please share a brief narrative of how your organization is responding to support the community through the water crisis.*

0/100
Please describe needs your organization and staff have during this time of crisis.

0/100
To Save Your ApplicationIf at any time you'd like to leave this form and save it in progress, please click on the next button and exit your browser. To resume your submission at a later time, return to the form from the link contained in your registration email. (YOUR BROWSER MUST BE ENABLED TO ACCEPT COOKIES. DATA IS SAVED LOCALLY IN YOUR BROWSER UNITL SUBMITTED) Technical AssistanceShould you have technical questions regarding the online submission process, please contact us at (614) 246-8904.

Grant Submission

CTP Funding Request
*

I certify that I am authorized by the the Executive Director and / or Board of Directors to submit this proposal on behalf of the organization. If I a submitting this with the support of a fiscal sponsor, I certify that that their authorizing official is aware of and approves submission of this request for funding.
*

I understand that by submitting this application I certify that all statements and representations are true and correct. I understand that I may be held civilly and/or criminally liable under federal or state law for knowingly making false or fraudulent statements.
*

I agree that the insertion of data into the following fields constitutes an electronic signature.
Signature

Clear
Name
Title
Date
Should be Empty:

EMERGENCY SUPPORT FOR JACKSON, MISSISSIPPI FUNDING REQUEST

Organization Information

Fiscal Sponsor Information

Contact Information

Financial Information

Fiscal Sponsor Information

Rapid Response Activities

Grant Submission