Claude Worthington Benedum Foundation
Grant Application
Please complete the Grant Application and Budget Forms so that we may consider your request for funding.
Organization Information
Organization Name
Legal Name
As appears on your IRS Tax Determination Letter.
Tax ID
Address
City
State
Postal Code
Phone
Fax
Website Address
Total of Current Annual Operating Budget
Format example (whole dollars only): $500,000
Organization History
Provide a brief narrative of the organization seeking funding. Include: mission and purpose; how long it has been in existence; and, services provided.
Patriot Act Compliance
TThe following information is requested to assist the Benedum Foundation in complying with the Patriot Act and related regulations.
Has your organization ever transferred funds, or do you intend to transfer funds, outside of the United States?
Do you anticipate engaging the services or persons or entities located outside the United States with respect to the
project for which you seek funding?
Is your organization a subsidiary, affiliate, or partner of or with any organization with international offices or
activities?
Primary Organization Contact Information
Fill in the fields below as they pertain to your Organization's Primary Contact (i.e. Executive Director, President, etc.)
Organization Primary Contact Name
Organization Primary Contact Title
Organization Primary Contact Office Phone
Organization Primary Contact E-mail
Organization Primary Contact Mobile Phone
Organization Primary Contact Office Fax
Project’s Primary Contact
If your Project Primary Contact is the same as your Organization Primary Contact check this box and do not fill
in the information regarding Primary Project Contact.
Project Primary Contact Name
Project Primary Contact Title
Project Primary Contact Address
(If different from organization address)
Project Primary Contact E-mail
Project Primary Contact Mobile Phone
Project Primary Contact Office Fax
Additional Contact Information:
If you have an additional contact, enter this information below.
Additional Contact Name
Additional Contact Title
Additional Contact Address (if different from organization address)*******
Additional Contact Office Phone
Additional Contact E-mail
Additional Contact Mobile Phone
Additional Contact Office Fax
Project Information
Name and one sentence summary of your project.
Requested Amount
Format example (whole dollar amounts only): $500,000
What is the opportunity or problem being addressed by this project?
List the strategies and activities that will address the opportunity or problem.
Describe the project for which funding is being sought.
Objective(s) of the project.
What is the target population served, if any?
Geographical area served by this project:
(Please check the appropriate box below)
West Virginia
Pennsylvania
Other
Outcomes: What do you hope to accomplish? Why do you think it will make a difference?
How will you and the Benedum Foundation know that you've made a difference; that is,
how will you measure success?
1) List at a minimum two specific activities with respect to each objective; and,
2) How you will measure success (use measurements of impact or benefit, not
measurements of process, where possible).
Proposed Outcome 1
Proposed Outcome 2
Proposed Outcome 3
Additional Proposed Outcome(s)
If you have more than three outcomes, please list additional outcomes below.
Implementation Plan: List the phases of project implementation and related activities,
including an estimated timeframe for each phase. (Examples: research & planning, pilot
testing, evaluation.) Timelines, implementation plans, charts, etc. may also be attached.
Sustainability Plan
Describe how the project will be financially and organizationally sustained at the conclusion of the grant.
Permission to Submit


You are authorized by your organization to submit this application.
You understand that as part of the Foundation's obligation to exercise due diligence with respect to
any grant and to comply with other legal requirements, the Foundation may seek information about
your organization and people involved with your organization from a variety of sources.
___________________________________________________ (Signature) _________________________
Name and Title
Date
Attachments - These documents MUST accompany this Grant Application:
Organization Budget (Document found on Benedum Foundation website)
Project Budget and Narrative (Document found on Benedum Foundation website)
AND
If: Nonprofit Organization:
1.
Copy of most recent Audited Financial Statement. If there is not an Audited Financial Statement, please
explain and attach a copy of the most recent 990.
2.
A list of the names, titles, and city or town of residence for the board of directors, chief executive officer, and
any other key personnel or volunteers involved in the project.
If: Government Entity:
1.
2.
Copy of most recent Financial Statement or equivalent.
A list of current members of the governance structure (e.g., Mayor and Council members) with titles, and city
or town of residence.