ApplicationSummaryForm

APPLICATION SUMMARY SHEET
(Attach this sheet to the front of your application)

1. Legal Name of organization: ________________________________________________________________

Address: _______________________________________________________________________________

Telephone: ______________________________________     Fax: _________________________________

Email address: ___________________________________      Web address: _________________________

Name and title of Contact Person: ___________________________________________________________

Name of Executive Director: ________________________________________________________________

Name of President of Board: ________________________________________________________________

Federal ID number: _______________________________________

2. IRS 501(c) (3) nonprofit? Please circle:           YES         NO
    If Yes, please attach copy of designation letter from the IRS.
    If No, you are not eligible for a grant from the Patricia Kind Family Foundation.

3. Amount Requested: $_____________________________________________________________________

4. Type of Grant Requested [Operating, Project, Challenge, Matching, Technology, Capital]: _______________

5.   State Your Organization’s Mission (2-3 Sentences):

6. Summarize the proposal and its strategic link with this funder, including the name of the project or the capital
campaign, if applicable (4-5 Sentences):

7. List the Proposal’s Target Population, Constituents, and Geographic Communities:

8. Total number of organization’s Board Members:__________________

9. Total number of organization’s Employees: Full Time______ Part Time_______Volunteer_______

10. Total annual organizational budget: $______________________ Dates of fiscal year: ______________

11. Project or capital budget (if applicable): $___________________

12. Time period this grant will cover:   ______________   to _____________

13. Does your organization receive support from United Way, Combined Health, Arts Council or any other
   federated funds? Please circle:   YES       NO

     If Yes, percentage of total operating budget supported by federated funds: __________%

14. List previous support from this funder, purpose, amount and date:



15. Signature of Executive Director: ___________________________________ Date: _______________