Tab 1

Grant Application Form

Complete the enclosed Grant Application Form.

Tab 2

Summary of Proposal

Provide a one-page summary of the proposal.

Tab 3

Mission Statement and Organization Purpose

Provide a brief, one-page mission statement and purpose of the organization.

Tab 4

Board of Trustees

Provide a one-page list of all members of the Board of Trustees of the submitting organization; the occupation of each; and any known relationships with GBHCMF, its employees, or Trustees.

Tab 5

Program Proposal

Provide a proposal narrative that describes the proposed program in detail and specifically addresses the series of questions listed below. Some questions may not be applicable to your program. Program objectives and timelines should be both specific and realistic. Ideally, the proposal narrative will be a well-written document of no more that five pages in length that provides the information necessary for the reader to make an informed funding recommendation. If appropriate, include an appendix with supplementary material; such as, literature reviews, data collection instruments, letters of support, program staff resumes, etc.

a) What is the purpose of the program?
Describe how the need and/or problem was identified and include specific evidence to support your position.

b) Who is expected to benefit from the program?
Describe the specific population (who and how many) and geographical area that will be targeted by the program.

c) What is expected to happen or be different as a result of the program?
Describe the specific changes that the program is expected to produce and how the target population is expected to benefit from the program.

d) How will the program work?
Describe the specific tasks and related timetables that will be required to implement the program.

e) Why will the program work?
Describe how the program was developed, with specific reference to related research, review of existing program models and results, solicitation of buy-in from the target population and other stakeholders, and identification of partners for program implementation.

f) Why is your organization best suited to operate the program?
Describe the history of your organization, its corporate structure, previous relevant accomplishments, and the work experience and educational background of staff to be assigned to the program. If other organizations are providing similar services to the target population, provide justification for creating a new program and discuss your efforts to collaborate with the existing organizations.

g) How will you know whether the program is successful?
Describe the expected outcomes (direct results) of the program in clear and measurable terms, including target dates. Provide specific indicators and/or benchmarks that will be used to determine the changes effected by the program.

h) How will you measure program performance?
Describe the specific data to be used and how it will be collected and describe how the data will demonstrate program performance.

i) How will you communicate your program results to the community?
Describe how you will inform all interested stakeholders about the successes and challenges of the program.

j) If the program is successful, how will it be sustained after the grant term ends?
Describe your plan to identify and secure funding to continue the program.

Tab 6

Program Budget

a) Provide a one-page Executive Summary Budget in accordance with the format below.

Organization Name _______________________________________

Program Name ___________________________________________

b) For each category of the program costs shown in the Executive Summary Budget, provide a detailed line-item budget for each year of the grant plus a separate budget narrative that includes a specific explanation for each budget line item. Following are information requirements for the line-item budget:

Personnel – Identify positions and related base salaries, associated fringe benefits (payroll taxes, insurance, retirement), and percentage of time each position is allocated to the program.

Direct Program Costs – include operating costs specifically attributable to the program; such as, supplies program materials, travel, postage, printing, etc.

Indirect Program Costs – include a pro rata share of operating costs of the entire organization that are necessary to conduct the program; such as, rent, utilities, equipment rental, insurance, audit fees, etc. The method of allocating a pro rata share of these costs to the program must be described and fully documented in the narrative.

Consultants – specify terms of each consulting agreement, such as name of consultant, fee and deliverables. Data collection, program evaluation, operating and/or financial technical assistance, and dissemination of results are examples of services that may need to be outsourced to an independent third party.

Equipment – itemize any equipment being requested and explain how it will be used to accomplish program objectives. Some examples are computers, printers, copy machines, and software.

c) For each item of program revenue shown in the Executive Summary Budget, provide specific information, including funding source, amount, term, and current status (pending or approved application).

Tab 7

Tax Status

Provide a copy of the most recent 501(c)(3) letter of determination of tax-exempt status issued to the organization by the Internal Revenue Service. The letter of determination must specify that the organization is not a private foundation described in Section 509(a) of the Internal Revenue Code.

Tab 8

Financial Statement

Provide the most recent audited financial statements of the organization. If audited financial statements are not available, provide the most recent internal financial statements.

Tab 9

Form 990

Provide the most recent Form 990 of the organization.