The Vernon D. & Florence E. Roosa Family Foundation

Grant Application


THE ORGANIZAITON:

1. Name of the Organization

Address
City, State, Zip
Telephone Number
Fax Number
Email Address
Website Address
Name of Chief Executive
Tax ID Number

2. Provide the name and contact information for the person responsible for the Grant Application, please include:
  • Telephone number
  • Fax number
  • Email address

3. State the mission of your organization.

4. List all services provided by your organization that represent 5% or more of the annual budget.

THE PROJECT:

1. Describe the proposed project. Include:

  • The purpose and goals of your project
  • The statement of need for your project
  • A description of the populations served by the project
  • Provide the number of individuals served by the project
  • The location of those served
  • The way in which you will measure the success of the project

2. Describe the implementation process for your project. Please include information on key staff and volunteer project managers.

3. Describe the time line for the project. Please be specific and include a statement of when the project will begin and when it will be completed.

THE BUDGET:

1. State the amount requested for the project.

2. Provide a time line of when the funds are needed.

3. List other sources of funding for the project, including applications submitted to other foundations. Show the status of all funding requests from these foundations.

4. Provide the name of the accounting firm that prepares the organization's annual audit.

5. State the tax year end of the organization.

6. Provide the budget for the project in as much detail as possible.

7. Provide a budget for the organization (state the tax year for which the budget is provided) in as much detail as possible.


ATTACHMENTS REQUIRED:

_____ IRS tax determination letter showing that you are a recognized public charity and that you are not a private foundation.

_____ The signed Statement from the Applicant Organization's Chief Executive Officer. Click Here for the Statement from the Applicant Organization's Chief Executive Officer form. The form opens in a new browser window in a print friendly format.

_____ A copy of the most recent audited financial statement of your organization.

_____ A copy of the organization's most recent annual report, if available.

_____ A list of the organization's board of directors or trustees, showing their names and business or volunteer titles.