Grant Application Form - Hospice Giving Foundation

Grant Application Form - Hospice Giving Foundation

Deadline: All applications must be received by 5 pm on May 1. Note: If you received a grant in the previous cycle, reports are also due on or before this date. If you have not submitted your final report, please do so prior to submitting this application.

Many of the fields in this application are required and are indicated by an *. It is recommended that you prepare your responses to the questions in a saved file prior to completing the form so that if system errors occur, you will not lose important work. Each question will show its word limit if one has been applied.

There are specific places for you to upload all required documents. Please make sure the uploads are not password protected. In general, pdf files are preferred. If there are issues with any uploads, please contact us.

Please do not upload marketing materials, photos, or other digital files not requested in the spaces below. We do not accept hard copy applications/materials.

We look forward to reading your request!
Section 1: Organizational Information
Full Legal Organization Name*
(Should be the same as on IRS determination letter and as supplied on IRS Form 990)
DBA (if applicable)
Tax Identification Number*
Organization Website*
Current Annual Operating Budget*
Date Organization was Founded*
Enter the last day of your fiscal year.*

MonthDayYear
Fiscal year end
Number of Full-Time Staff*
Number of Part-Time Staff*
Number of Volunteers Across Entire Agency*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Key Staff (person who will hold primary responsibility for this grant)*

First NameLast Name
Title*
Work Number*
Mobile Number
Additional Contact

First NameLast Name
Title
Work Number
Mobile Number
Mission and Governance Structure
Describe the primary purpose of your organization, relevant information to understand its mission, and it's governance structure.*

0/350
Section 2: Request Basics
Amount of Request*
Project Name

0/20
Executive Summary of this Request*

0/100
Please select type of support (select only one).*

General Support - For Overall Purpose, Operating Needs, and/or Strategic AgendaProject Support - For a Specific Program or Project
If this request is for a project or specific program, please indicate which category best fits this project (select only one).*

One-Time ProjectNew ProjectOngoing Program
What services will you offer using funds requested in this proposal? Please check all that apply.*

Hospice CarePalliative CareCaregiver SupportPsycho-Social Services for Individuals and FamiliesEducation and OutreachDirect Financial Assistance/SubsidiesGrief and BereavementSpiritual CarePediatric Palliative CareOther
Number of Paid Staff Assigned to this Project/Effort*
Number Volunteers with Project/Effort*
Given the scope of your organization and the work you currently do in the community, please rate the priority of the proposed work on a five point scale, with one as least important and 5 as a critical priority for your organization.*

1

2

3

4

5

1 is Less important, 5 is Most important
Section 3: Case for Support
Please provide a detailed description of the services, programs, and/or patient/family needs this funding will support. Explain how Hospice Giving Foundation funding will provide resources, beyond standard payor reimbursements, to enable your organization to elevate care for those with serious illness or nearing end of life. Include, as appropriate, data that supports the needs and how this program may address inequities in end-of-life care. *

0/1000
Intent: What of the following, if any, are intentional focuses of this request? Please select all that apply.*

To expand access in underserved communities (defined as either groups of people or regional areas), thus addressing healthcare disparities/inequities for end-of-life care.To provide innovative approaches to, or enhance, existing services for those facing serious illness or end of life.To expand collaboration with like-kind services or similar providers without duplication.To educate the community and/or professionals on options for end-of-life care or advance healthcare preparedness.To provide hospice or palliative care for adults and/or children.To improve family/patient satisfaction support and timeliness of services (re: Hospice or Palliative Care).Other
Brief explanation of above, if desired.

0/150
Objectives and Goals

You are required to enter at least one goal. Please be clear and brief.

List up to 6 priority objectives and goals, stated in measurable format (e.g. SMART goals).*

	Priority Objectives in Order of Importance
1.
2.
3.
4.
5.
6.

Specific Activities

You are required to enter at least one activity.

List and briefly describe the primary activities to be funded by this grant. Provide specifics such as frequency of activity and/or professional discipline providing service. *

	List of Activities
1.
2.
3.
4.
5.
6.

Sources of Support
Please list the sources of support and amounts of grants/donations/other support committed for this work, proposal pending, and any planned submissions. *

0/200
Project Budget Detail
In a narrative format, please provide specific details on how the requested funds will be used. *

0/300
Evaluation
Describe relevant industry standards, metrics, patient experiences and/or outcomes used to help you track success. How will your agency use your analysis/review of this program to guide and improve your practice?*

0/300
Section 4: Organizational Financial Overview
Financial/Budget Information
Please use this space to describe changes in any financial positions, notable increases or decreases to the operating budget, and/or planned-for deficit budgeting, if applicable. *

0/200
Sustainability and Economic Challenges
Use this section to describe fund development strategies to ensure sustainability of your programs as well as factors which may present fiscal challenges and/or obstacles to your program. Describe any unusual or special circumstances that would justify the amount of funding requested. *

0/300
Section 5: Statistical Information

This section replaces the Hospice Giving Foundation Statistical Worksheet.
Demographical Data

Please use the dates of July 1 (of this year) - June 30 (of next year) for the grant year.

Each answer should estimate the number of people your agency expects to serve through the end of the grant year.

Note: Final grant reports will require you to update your estimates with actual data from the grant year.

Gender*

	Estimated Number
Male
Female
Non-Binary
Other Gender

Automatic total of entries above (Gender)

Age*

	Estimated Number
Birth - 17
18 - 21
22 - 39
40 - 64
65+

Automatic total of entries above (Age)

Ethnicity*

	Estimated Number
Caucasian
Hispanic/Latinx
Asian American
African American
Bi-Racial/Other
Declined to Answer

Automatic total of entries above (Ethnicity)

Region*

	Estimated Number
Monterey Peninsula
Salinas Valley
South Monterey County
North Monterey County
San Benito County
Other

Automatic total of entries above (Region)

Socio-economic

The income limits listed below are taken from the 2023 State Income Limits Briefing Materials on California Code of Regulations, Title 25, Section 6932 published June 6, 2023 by the Department of Housing and Community Development. Levels are updated yearly for each county, using data from the American Community Survey of the Census Bureau. For more information visit https://www.hcd.ca.gov/sites/default/files/docs/grants-and-funding/income-limits-2023.pdf

Please use the Monterey County chart below to guide your answers for the following question.

*Number of people in household*	1	2	3	4
Acutely Low	$10,500	$12,050	$13,550	$15,050
Extremely Low	$25,300	$28,900	$32,500	$36,100
Very Low	$42,150	$48,200	$54,200	$60,200
Low	$67,460	$77,100	$86,750	$96,350
Median	$70,300	$80,300	$90,350	$100,400
Moderate	$84,350	$96,400	$108,450	$120,500

Income Limits for Monterey County*

	Estimated Number
Acutely Low
Extremely Low
Very Low
Low
Median
Moderate
Above Moderate

Automatic total of entries above (Income Limits for Monterey County)

Patients by Service*

	Estimated Number
Hospice Care
Caregiver Support
Education and Outreach
Grief and Bereavement
Pediatric Palliative Care
Palliative Care
Psycho-Social Services for Individuals and Families
Direct Financial Assistance/Subsidies
Spiritual Care
Other

Automatic total of entries above (Patients by Service)
Please estimate the increase in the number of people you will be able to serve with funding from Hospice Giving Foundation.*
Do you receive CAHPS Hospice Survey Satisfaction rankings? If no, please skip the next question.*

YesNo

CAHPS Hospice Survey Most Recent Ranking Data - please use the current fiscal year for this data.

	Interim Rank	Final Rank
Team Communication
Getting Timely Care
Treating Family Members with Respect
Emotional and Religious Support
Getting Help from Symptoms
Getting Hospice Care Training
Rating of Hospice
Willingness to Recommend

Section 6: Required Attachments
Organizational Documents
Please upload a Current Copy of your IRS Determination Letter *

501(c)(3) verification
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Letter from the Board Chair or Designee Supporting this Request*

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For Hospital Foundations Only: Letter of Commitment Signed by Hospital Leadership and/or Medical Director of the Program for which Funds are Requested

Cancelof
List of the Board of Directors with Affiliations and Cities*

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List of the Key Employees with Titles*

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Financial Documents
Current Approved Annual Budget and, if needed, an Approved Funding- Year Budget*

*Hospice Giving Foundation awards have a grant term of July 1 – June 30. If your organization has a different fiscal year, a board-approved funding-year budget is requested. If your budget is not yet approved, you may submit an estimated budget, noting the date approval is expected below. Two files can be uploaded to this field.
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Has this Annual Budget been approved by your board?*

YesNo
If not yet approved, please provide the date the approval is expected.

MonthDayYear
Date
Current Year-to-date Budget vs. Actual Report*

For the most recent month completed
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Profit and Loss Statements for the Most Recent Fiscal-Year End*

Most recently completed fiscal year
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Balance Sheet for the Most Recent Fiscal-Year End*

Most recently completed fiscal year
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Grant Request Budget *

You may use your own budget or use Hospice Giving Foundation's template.
Cancelof
Audited Financial Statement for the Most Recently Completed Fiscal-Year; Organizations with Operating Budgets less than $900,000 may submit a Financial Review *

Please double check for password protections on audit files.
Cancelof
By submitting this document, I certify, to the best of my knowledge, that all information (provided in the documents uploaded and the appllication) is true and correct.
Signature*

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Grant Application Form - Hospice Giving Foundation

Section 1: Organizational Information

Mission and Governance Structure

Section 2: Request Basics

Section 3: Case for Support

Objectives and Goals

Specific Activities

Sources of Support

Project Budget Detail

Evaluation

Section 4: Organizational Financial Overview

Financial/Budget Information

Sustainability and Economic Challenges

Section 5: Statistical Information

Section 6: Required Attachments

Organizational Documents

Financial Documents