Assignment 8.3

    Student Name:

    Date:

     

    COMMON APPLICATION FORM

    Cover Page

     

    Organization Name:

    City, State:

    Website:

    Chief Executive Officer:

     

    Purpose of the request: A brief summary of the amount requested and its purpose:

     

    Amount:

    Purpose:

     

     

     

     

     

     

     

     

    FUNDING REQUEST – 65 points:

    1. State the underlying need, problem or opportunity (Needs Statement): 1 page, 20 points

    2. Project Description/Implementation Plan: Brief description of the proposed project: New project? Expansion of existing project? Describe the primary components. 1-1/2 pages – 20 points

    3. Effect: State the goals and objectives and the effect on the need, problem or opportunity: ½ page of less, 5 points

    4. Population Served: Who and how many, geographic area, socio-economic status, ethnicity, gender, age, physical ability, language. – ½ page or less, 5 points

    5. Partnerships: Who are you partnering with and what will they provide.

    6. Work Plan: Project timeline – this can be in quarters – 1st quarter, 2nd quarter, 3rd quarter, 4th quarter, primary tasks: ½ page or less, 5 points

    7. Evaluation Plan (Process Evaluation and Outcome Evaluation): ½ page or less, 5 points

    8. Sustainability: ½ page or less, 5 points

    BACKGROUND OF THE ORGANIZATION: – all 3 sections 1 – 1 ½ pages – total of 15 points:

    1. History and Mission – brief description

    2. Key programs in existence

    3. Staff expertise relevant to this proposed project.

    ANNUAL FINANCIAL PLAN: (You can add or skip budget categories, but you must include Fringe if you have Personnel costs, and include Administrative costs). 30 points:

    Line Item Budget

    For this Request

    Personnel

     

    Fringe

     

    Travel

     

    Supplies

     

    Contractual

     

    Other

     

    Administrative costs (10% of total)

     

    TOTAL

     

    Budget Justification – explanation of content of each line item: 10 points

    1. Personnel and fringe:

    2. Travel:

    3. Supplies:

    4. Contractual:

    5. Other:

    6. Administrative:

    References

    1

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