SELF-CERTIFICATION CHECKLIST FORM
ORGANIZATION BACKGROUND
Full Legal Organization Name: ________________________ Organization Website: ____________________
Street Address:__________________________ City:______________ State:_________
Zip:__________
Organization President/CEO/Executive Director Name: _______________________________________________
Phone Number: _____________________
Email Address: ________________________________________
Contact Person (if different): __________________________________ Title:_____________________________
Phone Number: _____________________
Email Address: ________________________________________
Established: ______(year)______
Grant Amount Requested: $________________
A 501c3 organization: Yes No
Program Area: __________________________
Community Welfare, Culture, Environment, Health, Urban &
Community Affairs, or Education
This request is a (circle one): Renewal of a prior grant; a Capital Request (50% must already be raised or committed); an
Operating Request (only eligible for those organizations that are less than five years old); either a Program or Project
Request; or, a request for Technical Assistance.
Project title: ______________________________________________________________________________
What Chicago geographic community area does your organization serve directly? _____________________
(Citywide or one of the 77 community areas: http://www.encyclopedia.chicagohistory.org/pages/1760.html )
Mission Statement:
FINANCIAL INFORMATION
BUDGET:
Organization’s current Fiscal Year budget size: $ __________________________ e.g. $1,050,000
Operates on a 12 month fiscal year that ends on (date): ______________________ e.g. June 30
AUDIT:
Audited financial statements and/or an IL990 for the year ended ___________________________
(E.g. June 30, 2013) are included with the proposal.
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PROPOSAL REQUEST
Project budget size: $ __________________________
Foundation support will serve the __________________________ (write in one of the 77 Chicago community areas
http://www.encyclopedia.chicagohistory.org/pages/1760.html or if more than one community area, write in “citywide”).
Who will be served by this project (Include demographic information):
E.g. 15 low-income Latino teens from Chicago Public Housing, 1,000 Asian senior citizens from assisted living homes
throughout Chicago, 22 African American parents with public school children, 75 Polish 5-12 year old English language
learners, 200 low-wage immigrant workers, three homeless families etc.
Foundation support would be specifically directed toward expenses for: __________________________
E.g. A portion of a new program manager position’s salary, installation of a new sprinkler system, 100 hours of an
instructor’s time for after school workshops (A maximum of two sentences).
ORGANIZATIONAL DIVERSITY
The Field Foundation values board, management and staff diversity among its grantees. The Foundation
recognizes that diversity is expressed in different ways such as race, gender, religion, ability, economic status,
sexual orientation, national origin, and age. Please complete the chart below with whole numbers.
BOARD:
Total Number: _________
Women: _______
People of Color: _________
MANAGEMENT:
Total Number: _________
Women: _______
People of Color: _________
STAFF:
Total Number: _________
Women: _______
People of Color: _________
If applicable, please feel free to provide a brief description of additional forms of diversity present within the
organization.
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SELF-CERTIFICATION CHECKLIST FORM
PROPOSAL AGREEMENT
The Field Foundation (Foundation) submission form and supplemental materials provides the Foundation with the
information necessary to begin its evaluation of the request. Once the proposal packet has been received, the
Foundation will send a notification postcard in the mail to indicate that the review process is underway. All materials
should be sent together in a complete packet and must be delivered in hard copy to the Foundation at 200 S.
Wacker Dr. Suite 3860 Chicago, IL 60606 by 5pm of the deadline date. The Foundation does not accept emailed or
electronic proposals.
In addition to the Self-Certification form and Proposal Agreement, please include the following materials to the
Foundation. Only one copy of each of the listed materials is required.
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A cover letter outlining the proposal;
A proposal narrative that provides a framework to the request as well as the organization’s brief history. In total,
the narrative should be no more than seven pages;
A separate project budget that indicates income and expense;
A separate agency budget for the current fiscal year;
A current audit (no more than 12 months old);
A list of the organization’s board members with employment affiliations;
A list of current agency funders; and,
A copy of the IRS 501c3 nonprofit designation letter.
Please read carefully. In completing this form, I confirm that the organization I represent can be included in one of the
following areas: Community Welfare, Culture, Environment, Health, Urban & Community Affairs, or Education. A
majority (more than 50%) of the people served by the organization reside in Chicago and the organization is not seeking
operating funds (if the organization is more than five years old).
Further, I certify that funds are not being sought for the following reasons: Medical research, lobbying (propaganda or
influencing legislation), fundraising events or advertising, religious appeals or purposes, re-granting by other agencies or
foundations, day care centers (adults, children, pets), endowments, individuals, profit-making businesses, printed
materials, video or computer equipment, software, the elimination of an accumulated operating deficit, disease-specific
voluntary associations, development or fundraising staff positions, expenses for an artistic production (media, theater,
music, film, dance, interdisciplinary) other than outreach to underserved populations, assistance to the administration of
the Chicago Board of Education, scholarships, operating expenses of local school councils, repairs and/or improvements
to public school buildings, or degree-granting programs offered through higher education institutions.
If your organization is working with a fiscal agent on this proposal, please complete the supplemental information.
Organization Signature and Date:
i.e. /Susan Q. Public/ for XYZ organization on January XX, 2016
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FISCAL AGENT INFORMATION
Complete only if using a fiscal agent:
Name of Fiscal Agent: __________________________
Contact Name: ___________________________
Address: _________________ City: _________________
State: _______________
Phone: _________________
Website: _________________
Email: _________________
Zip Code: _____
Is the fiscal agent currently receiving Field Foundation support? Yes No
Has the fiscal agent received Field Foundation support in the past? Yes No
The following documents should be included in the proposal for the fiscal agent:
 Audit or Illinois 990 form
 Agency Financial Statements
 Board list with employment affiliation
 IRS 501(c)(3) letter
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