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
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