Ms Molly Grant Application

2024 Ms. Molly Foundation Grant Application

Application Deadline - October 31, 2024. Please note a new application must be submitted every year.
Domestic Violence Agency Information
Agency Name*
Does your agency have a 501c3 status?*

YesNo
Is your agency Domestic Violence focused?*

YesNo
Tax Identification Number*
Agency Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency Phone Number*
Agency Website*
www.sample.com
Date Established*
Fiscal Year*
Mission Statement*
Contact Information
Contact Name*

First NameLast Name
Contact Title*
Contact Email*
Tell us which Molly Maid location you are working with (DBA, Office Location, Contact)*
Agency and DV Background:

To better understand the focus of your agency, please answer the following questions.
Is Domestic Violence your agencies primary focus?*

YesNo
What is your Agency’s Domestic Violence focus?*

Prevention Based ProgramsSupport Based ProgramsBoth Prevention and Support Based ProgramsOther
What county(ies) do you serve?*
Do you offer shelter services?*

YesNo
Do you offer shelter services to men?*

YesNo
Please describe*
How many men received shelter services in 2023?*
How many children received shelter services in 2023?*
How many women received shelter services in 2023?*
Describe the population that you serve*
What type of service(s) does your agency provide? Check all that apply.*

24 hour hotline servicesEmergency shelterTransitional housingVictim Services (Crisis intervention, court advocacy, financial aid, legal advocacyPeer based support groupsCrisis counselingSelf-protection seminars for womenJob readiness programsChildren’s programmingReferrals, information and resource materialsAwareness presentations for parents, community groups/membersPrevention education programs in schoolsAgency newsletterAbuser Intervention ProgrammingCommunity domestic violence awareness activitiesAssistance for those who are non English speakingOther
Domestic Violence Outcomes/Funding:
What are the targeted domestic violence outcomes? Please check all that apply.*

Ability to identify persons or groups with high risk of becoming victims or abusersPromote prevention behaviorsProvide treatment strategies for victimsEnable survivors to lead productive lives through Housing, Education & JobsUse technology as an empowering tool for safety and communicationPrevention EducationSurvivors’ immediate safety (for residential services)Immediate safety of survivors’ children (for residential services)Survivors’ increased knowledge about domestic violenceSurvivors’ increased knowledge of resources and optionsSurvivors’ decreased isolationCommunity’s improved response to battered women and their childrenPublic’s increased knowledge about domestic violenceOther
What types of children’s programming is being offered by your agency?*
How are your Domestic Violence programs outcomes measured, tracked and collected? Please be specific.*
How do you intend to use any funding provided by the Ms. Molly Foundation? Be specific.*
Ms. Molly Participation:
How has support/funding from the Ms. Molly Foundation helped your organization.*
Understandings and E-Signature
This form and all required documents (see below) must be submitted by October 31, 2024 to be considered for funding. You will receive notification via email that your application has been approved for funding. If you are approved for funding, checks will be mailed in December.

The following items need to be on file with Foundation:

• 501c3 certificate
• IRS Form 990 return for the last fiscal year
• Current signed W9
You can upload your files here, or send them to mrobles@msmolly.org

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Shelter Representative Typed Name
Shelter Representative E-Signature
We encourage you to print this document and save it for your records.
Please note for your records the Ms. Molly Foundation mailing address:

Ms. Molly Foundation

480 N. Canton Center #87705

Canton, MI 48187
Should be Empty:

2024 Ms. Molly Foundation Grant Application

Domestic Violence Agency Information

Contact Information

Agency and DV Background:

Domestic Violence Outcomes/Funding:

Ms. Molly Participation:

Understandings and E-Signature