Fall 2016 Request for Funding Form

One-Time-Only Funding Fall 2016 Request Form
Equity and Access Committee
1.) Name, office of Requester and contact information, including telephone number:
2.) Title of Project: ______________________________
3.) Requested Amount $__________ (Complete the budget worksheet below and
thoroughly demonstrate all anticipated revenues and expenses). $ 5,000.00 maximum
On a separate page(s), please respond to each of the following (limited to 500 words total):
A. If this program was funded in a prior year through another program, please identify the
source of those funds and explain why these funds are no longer available to support the
program or activity.
B. Fully describe the intended use of the funds requested, the proposed schedule of events,
and attach any supporting documents. Be sure to identify why Equity and Access funds
should be used to support this initiative.
C. Indicate the University Goal outcome that this request supports and explain how the
proposed activity will help fulfill that goal.
D. What is the anticipated impact (either initial or projected long term, number of students
served, immediately and/or potentially) of this proposal on Texas State?
E. Preference will be given to those proposals that include matching funds (grants,
donations, use of volunteers and other in-kind contributions) and plans for continuation
of activities. How will your project leverage the funds provided from this grant with
other current or future resources?
Representative Signature and Date
Co-Sponsor Signature and Date
Co-Sponsor Signature and Date
Co-Sponsor Signature and Date
Department Chair, if applicable, and Date
Dean/Director Signature and
Comments from Office, Department or Divisional Representative:
Budget Worksheet
Title of Project: _________________________________
Please use the table below to specify the use of the funds:
Equity and Access Committee
Funds Requested
Other Funding Sources
Category & Source
Faculty Salaries
Graduate Salaries
Adjunct Salaries
M&O (67200)
Total Equity and Access
Committee Funds Requested
Other Funding Sources
Total Cost of Project