John F. Wegman Fund. Eligibility Questions. Rochester Area Community Foundation. Eligibility Conditions:*

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1 John F. Wegman Fund Rochester Area Community Foundation Eligibility Questions Before submitting a request to the John F. Wegman Fund, read the Eligibility Conditions below to ensure that your organization and request for funding meet the needed requirements. You can learn more about these requirements by returning to the John F. Wegman Fund Profile Page here. Eligibility Conditions:* 1. Your organization must be classified by the IRS as a 501(c)(3) organization or a 509(a)(1) public organization. (If not, you must have a fiscal sponsor for this request). 2. If approved for funding, the funds must be used primarily to serve individuals in Monroe County. 3. Applications must be received at least 6 months before the program start date. 4. You have read the Funding Priorities for the John F. Wegman Fund found on the Community Foundation website. Please note Applications will not be considered from organizations that have received funding from the John F. Wegman Fund in the past 15 months, or has yet to submit a final report. Have you read all Eligibility Conditions listed above and want to continue to the application? o Yes o No 1

2 IRS Tax Status Click the GuideStar button in the top right corner of your screen to easily import your organization's EIN number, incorporation year and website URL directly into this application! Note: In order to ensure that the most up to date information is imported, it is recommended to update your GuideStar information regularly. 9-digit Federal Employer ID #* Incorporation Year* Letter of Determination* Is the name of the organization you listed above the same as it appears on the IRS 501(c)(3) or 509(a)(1) Letter of Determination? Choices o Yes o No Letter of Determination Followup If the organization name DOES NOT match the IRS Letter of Determination, please explain the reason for the difference and indicate the appropriate organization's name to be used for the grant. Fiscal Sponsorship Fiscal Sponsorship Form (REQUIRED if applicant is not a 501(c)(3), or 509(a)(1) public organization) Please download this Fiscal Sponsorship Agreement form if another organization is serving as your fiscal sponsor. Upload the completed form into this application by clicking the 'Upload a file' button below. 2

3 Organization Information Executive Name* Executive Title* Executive * Website Board of Directors* Include a listing of your organization's Board of Directors with their affiliations. Organization Demographic Survey* Please download this Organization Demographic Survey form. Upload the completed form into this application by clicking the 'Upload a file' button below. Letters of Support You may upload any letters of support from partner agencies by click the 'Upload a file' button below. Please note: Only one file can be uploaded. If submitting more than one letter of support, you must combine all documents into one file 3

4 Revenue and Expenditures Fiscal year* What is Your Fiscal Year? (Jan-Dec, July-June, etc.) Budgeted revenue for fiscal year* Total Budgeted Revenue for Current Fiscal Year Budgeted expenses for fiscal year* Total Budgeted Expenses for Current Fiscal Year For the following set of questions, enter the % of revenue your organization receives from each of the sources listed below. % of revenue from fees* % of revenue from fundraising* % of revenue from government* % of revenue from grants* % of revenue from investment income* % of revenue from membership* % of revenue from United Way* Recent One-Page Organization Budget* Recent One-Page Organization Budget Please upload a one-page financial summary of your organization's most recently completed, and preferably audited, fiscal year. Upload your document into this application by clicking the 'Upload a file' button below. Your document should reflect the budgeted and actual revenues and expenditures (be sure to note the fiscal year in the text box below). 4

5 Information for This Request Contact Person* Contact Number* Contact fax Contact * Project Name* Total Cost* Amount Requested* Date Needed* Date Spent* Request type* o Program/Project o General Support o Other (please describe in next question) Other Sources List other potential and actual sources of support. Please include the funder name and the dollar amount you are expected to receive or have received, e.g., Rochester Area Community Foundation $5,000. Put an "*" by those committed, noting any matching fund requirements. Character Limit: Funding History List major funders of this program/project for the past two years (if applicable). Please include the name of the funder and the dollar amount you received, e.g., Rochester Area Community Foundation $5,000. 5

6 Program/Project Budget Program/Project Budget Sheet* Program/Project Budget Worksheet. Upload the completed form into this application by clicking the 'Upload a file' button below. Brief Budget Narrative* Include a brief budget narrative of no more than 500 words to explain your budget (i.e. number of staff; type of consultant and rate; number of training sessions, etc.) Specify the basis for all calculations, for example the number of hours at so much per hour, number of miles at so much per mile, type and number of supplies at so much per unit. Executive Summary Activity Description* One Sentence Activity Description Need Addressed* Target Population* Goals/Objectives* Measurable Project Outcomes* 6

7 Using the text boxes below, describe up to five (5) of the main activities of your program/project. Activity #1: Activity #2: Activity #2: Activity #3: Activity #3: Activity #4: Activity #4: Activity #5: Activity #5: 7

8 Program/Project Description Summary of Program/Project* Describe the program/project in detail. Need for your planned work* Summarize the need for your planned work. Cite any research documenting the need, if available. Demand for your proposed project* Summarize customer demand for your proposed project. (Waiting lists, unfulfilled requests, etc.) Outcomes* What do you expect to achieve through this project? Evaluation* What will you measure to know if you reach your outcomes? Target* By when will you achieve the outcomes? Resources & Activities* Describe what you propose to do, how you will do it, how it will help you reach your outcomes, and the resources that you will access or use. Organizational Capacity: Mission* What is your organization s mission and how does this project relate to it? Organizational Capacity: Past Accomplishments* Summarize the past accomplishments of this or similar projects. If your organization has no similar experiences, explain why you are qualified to undertake this program/project. Links with Other Agencies* Indicate the name and role of collaborative partners, if any. Include letters of support if relevant. Future of project beyond grant period* What is the future of this project beyond the grant period? Support of project beyond grant period* If it is to continue beyond the grant period, how will you support this project? 8

9 Logic Model Applicants requesting $7,500 or more, or any request with a total project budget of $15,000 or more, MUST complete all Logic Model questions Program/Project Timeframe Program/Project Goal Key Stakeholders List the names and titles of those with key roles in developing logic model Inputs Inputs include financial assets, volunteers, materials and other required resources. Please quantify inputs whenever possible (e.g. "2.5 FTE social workers", "270 volunteer hours") Activities What does the program/project do with the inputs in order to achieve its outcomes? Activities should be quantified (e.g. 2 support groups/10 moms ea./2 hrs/wk for 4 mos.) Finish your Logic Model by explaining the Project Outcomes of your program/project. For example, the effects on knowledge, attitudes, skills, behavior, condition or status or after the program/project. Projected Shorter-term Outcomes Place a * next to those to be measured Projected Longer-term Outcomes Place a * next to those to be measured 9