Week 8.3 Paper

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:

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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