Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
Wells Fargo, which manages the Barsumian Trust, only accepts grant requests submitted
through its online application form. Research Development prepared the following
boilerplate language to help investigators complete the online form. The boilerplate
language mirrors the form fields in the online application. Investigators are welcome to use
this drop-in text, at their discretion, to prepare grant applications for submission to the
Barsumian Trust. Notes that appear in red font are for information purposes and should
not be inserted into your grant application. This document was last updated on July 11,
2015.
HELPFUL REFERENCES
Penn State University’s Board of Trustees
http://www.psu.edu/trustees/membership.html
Penn State University’s Audited Financial Statements (year end June 30, 2014)
https://controller.psu.edu/sites/default/files/users/controller/docs/RightToKnowReport2014.pdf
Penn State University’s 2014-15 Operating Budget
http://budget.psu.edu/openbudget/default.aspx
College of Medicine’s Office of Research Affairs (ORA)
http://www.pennstatehershey.org/web/researchaffairs/home
General Counsel’s letter of opinion regarding the University’s tax-exempt status
http://www.research.psu.edu/osp/documents/proposal/tax
TAX EXEMPT STATUS
Federal taxpayer identification number
Federal tax identification number of tax-exempt organization applying for grant
246000376
Organization name per Internal Revenue Service records
The Pennsylvania State University
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
Fiscal agent or sponsor?
If any grant funds awarded would be used by an entity other than the tax-exempt organization identified above,
describe the relationship between such other entity (ies) and the identified organization.
Grant funds will be administered by and used by the Penn State College of Medicine, a college of
The Pennsylvania State University that is based in Hershey, PA.
Tax exemption date
Date of most recent Internal Revenue Service determination letter recognizing organization’s tax-exempt status
September 9, 1949
Entity type
Enter the Internal Revenue Code sections describing the organization’s tax-exempt status as recognized by the
Internal Revenue Service.
The Pennsylvania State University has a Tax Determination Letter under IRC Section 115 of the
Internal Revenue Code. For federal income tax purposes, contributions to the Pennsylvania
State University are deductible against the income of individuals under IRC Section 170(c) and
IRC Section 170 (b)(1)(A)(v).
Additional exemption status comments (optional)
The original Tax Determination Letter from the IRS is dated September 9, 1949. This status is
reviewed and verified annually by the University’s Office of General Counsel.
CONTACT INFORMATION
Organization Name
Enter the full legal name of the organization to be contacted regarding this application.
The Pennsylvania State University
Also Known As/Doing Business As
If the organization is known by other names, enter each such name below
This field should be left blank
Mailing Address
Office of Research Affairs
Penn State College of Medicine
Penn State Milton S. Hershey Medical Center
Mail Code H138
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
500 University Drive
City
Hershey
State
Pennsylvania
Zip Code
17033
Physical address
(if different from mailing address)
This field should be left blank
Main Phone
717-531-8495 (Office of Research Affairs)
Website
http://www.pennstatehershey.org/web/researchaffairs/home
Email address for general inquiries
e-grants@hmc.psu.edu
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
PRIMARY REQUEST CONTACT
Requests for external funding submitted by investigators with appointments at the College of Medicine
must be reviewed by the Office of Research Affairs (ORA) prior to submission. Signing Officials for the
College reside within the Office of Research Affairs (ORA), which is the entity with the legal authority
to bind the College to a grant. Stephanie Johnson, Director of Grants Administration for ORA, must be
listed as the “primary request contact” for this application.
Prefix (Mr., Mrs., Ms., Dr., etc.)
Ms.
First name
Stephanie
Middle name/initial
This field should be left blank
Last name
Johnson
Suffix
This field should be left blank
Title
Director of Grants Administration
Email address
e-grants@hmc.psu.edu
Office Phone
717-531-8495
Mobile Phone
This field should be left blank
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
REQUEST SUMMARY
This section to be completed by the PI
Requested amount
Type of support (select from drop-down menu)
Request/project title
Request summary
Describe specific purposes for which any grant funds awarded from this foundation will be used
(e.g., specific equipment, overall project funding, etc.). This field is limited to 150 words.
Common goals
Why do you believe a grant to your organization would further this foundation's mission and priorities of our
foundation? This field is limited to 150 words.
Program area served (select from drop-down menu)
Geographical area served (select from drop-down menu)
Population served (select from drop-down menu)
Age group served (select from drop-down menu)
Gender served (select from drop-down menu)
Demographics comments (optional)
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
REQUEST DETAIL
This section to be completed by the PI
Describe the objectives of the project or program to be funded.
This field is limited to 150 words.
Describe the implementation plan for the project or program. Include at least three
specific actions your organization will take in order to achieve results.
This field is limited to 150 words.
What criteria does (or will) your organization use to measure the success of the
project or program?
This field is limited to 150 words.
Collaboration
Briefly describe any formal or informal collaborative ventures your organization has established (or will establish)
with other entities serving similar purposes that may be relevant to this grant request. This field is limited to 150
words.
Project background
If this grant request relates to an ongoing project or program, how long has the project or program been
operating? This field is limited to 150 words.
Start date
If a grant is awarded, when does your organization anticipate being able to begin using the funds for the requested
purpose?
Special Note: Historically, the Wells Fargo Barsumian Trust has conducted application reviews in the
Fall and announced awards at the end of the year based on a January 1 start date. Grants are
generally for 12 month terms.
End date
If a grant is awarded, when would the requested funds likely be exhausted?
Timeline
Provide any other relevant dates relating to the project or program for which grant funds would be used
(milestones, interim check-ins, etc.).
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
Project budget total (U.S. dollars)
Project budget detail
Provide a concise budget for the project listing major expense categories (if requesting general operating support,
enter “not applicable”).
Please note that the Barsumian Trust only provides grants to support medical research.
Other project funding
List other sources that may fund this project. Include other pending grant requests, providing entity name, amount
requested, and current status of each. If these sources do not fully fund the project, what other sources of funding
will your organization pursue?
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
ORGANIZATION DETAILS
Organization type (select from drop-down menu)
Select “health” from the drop-down menu
Mission
Briefly summarize your organization’s current mission. This field is limited to 100 words.
The Pennsylvania State University spans 24 campus locations statewide. “Priorities for
Excellence,” the University system’s 5-year strategic plan, was adopted by the Board of Trustees
in May 2009. The planning process was guided by a University Strategic Planning Council, which
gathered input from a broad cross-section of stakeholders, including individual colleges and
departments. “Priorities for Excellence” emphasizes a 3-pronged mission: to pursue excellence
in teaching, research, and public service. At the College of Medicine, this mission is evidenced by
a commitment to biomedical research, dedication to compassionate patient care, and the
education of tomorrow’s health professionals.
Board members
List your organization’s current board members, officers, and trustees, as applicable. Please limit each entry to one
line only. Extra blank lines are not needed between entries. Example: Board member’s full name, title at your
organization, name of other employer & professional title (if applicable)
As a unit of The Pennsylvania State University, the College of Medicine is under the purview of
the Board of Trustees for the Pennsylvania State University. The names of the trustees currently
serving on the 32-member Board are as follows:
Ex-Officio Members
Eric J. Barron, President, The Pennsylvania State University, Secretary of Board of Trustees
Thomas W. Wolf, Governor, Commonwealth of Pennsylvania
Pedro A. Rivera, Secretary, Pennsylvania Department of Education
Cynthia A. Dunn, Secretary, Pennsylvania Department of Conservation and Natural Resources
Russell C. Redding, Secretary, Pennsylvania Department of Agriculture
John Hanger, Secretary of Policy and Planning
Appointed by the Governor
Clifford G. Benson, Jr. Chief Development Officer, Buffalo Sabres
Mark H. Dambly, President, Pennrose Properties, LLC
Todd L. Rucci, Government and Community Relations Officer, PAP Technologies
Paul H. Silvis, Vice Chairman of the Board of Trustees and Head Coach, SilcoTek
Allison S. Goldstein, graduate student, The Pennsylvania State University
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
Elected by Alumni
Robert C. Jubelirer, Partner, Obermayer, Rebmann, Maxwell & Hippel
Albert L. Lord, March Wren, LLC
Edward “Ted” B. Brown, President & CEO, KETCHConsulting, Inc.
Barbara L. Doran, Portfolio Manager/Private Wealth Advisor, Morgan Stanley
Anthony P. Lubrano, President, A.P. Lubrano & Company, Inc.
Ryan J. McCombie, Independent business consultant
Alice W. Pope, Associate Professor, St. John's University
William F. Oldsey, Independent Consultant/Educational Publishing; Operating Partner, Atlas
Advisors
Robert J. Tribeck, Attorney, Post Acute Medical, LLC
Elected by Delegates from Agricultural Societies
Donald G. Cotner, President, Cotner Farms, Inc.
Keith W. Eckel, Owner and President of Fred W. Eckel and Sons Farms, Inc
M. Abraham Harpster, Co-Owner, Evergreen Farms, Inc.
Betsy E. Huber, Government Relations Director, Pennsylvania State Grange
Keith E. Masser, Chairman and CEO of Sterman Masser, Inc
Chris R. Hoffman, Vice President, Pennsylvania Farm Bureau
Elected by the Board Representing Business and Industry
Daniel Mead, President of Strategic Initiatives, Verizon Wireless
Richard K. Dandrea, Attorney, Eckert Seamans Cherin & Mellott, LLC
Robert E. Fenza, Retired COO, Liberty Property Trust
Ira M. Lubert, Chairman and Co-Founder, Independence Capital Partners and Lubert Adler
Partners, L.P.
Mary Lee Schneider, Former President and CEO, Follett Corp.
Walter Rakowich, Retired CEO, Prologis
Elected by the Board At-Large
Kathleen L. Casey, Senior Advisor, Patomak Global Partners, LLC
Julie Anna Potts, Executive Vice President and Treasurer, American Farm Bureau Federation
Matthew W. Schuyler, Chief Human Resources Officer, Hilton Worldwide
Number of paid staff, full-time
15,672
Source: Penn State Fact Book (Fall 2014)
Number of paid staff, part-time
5,890
Source: Penn State Fact Book (Fall 2014)
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
Number of volunteers
Thousands (University-wide)
400 (at the Penn State Hershey Medical Center)
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
ORGANIZATION FINANCES
CURRENT FISCAL YEAR FINANCES
Special Note: As of July 13, 2015 The Pennsylvania State University did not have an approved budget
for FY 2015-16. The following budget detail was taken from the FY2014-15 budget, which extended
from July 1, 2014 through June 30, 2015. Budget information can be accessed online through the
University’s Budget Office at http://budget.psu.edu/openbudget/default.aspx
Total annual budget
Enter the total amount (in U.S. dollars) of your organization’s annual budget for its current fiscal year.
$4,638,773,592
Organizational budget detail
Provide a brief budget for your current fiscal year that breaks down the above overall total by category. Suggested
categories: program services, salaries, fundraising, capital improvements, equipment, recruiting, etc.)
Institutional Support
Academic Support
Student Services
Instruction
Research
Extension and Public Service
Student Aid
Physical Plant
Employee Benefits
Special Provisions
Salaries
Wages
Dept. Allotment (inc. employee benefits)
Restricted Funds
The Milton S. Hershey Medical Center
TOTAL
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Total University
276,823,663
288,224,789
106,757,864
528,336,791
40,622,895
29,198,956
54,135,349
216,373,741
517,344,887
31,807,563
92,119,658
16,485,158
311,588,278
640,975,000
1,487,979,000
$4,638,773,592
College of Medicine Only
$
$
$
$
43,743,740
327,494
76,513,619
90,000,000
$214,417,809
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Budget Changes
Boilerplate Language for Grant Applications
Summarize any significant changes in your current year budget since initially established.
The University’s FY 2014-15 operating budget is $4.6 billion – a modest 0.26 percent increase
from the FY 2013-14 operating budget.
What percentage of your budget is allocated to administrative expenses?
12 percent of the University’s budget is allocated to administrative expenses
PRIOR FISCAL YEAR FINANCES
Complete the following sections using information included on your organization’s
most recently filed tax return.
Enter “N/A” for items that are not applicable. If your organization does not file a tax return, use information from
its most recent financial statement.
Source:
https://controller.psu.edu/sites/default/files/users/controller/docs/RightToKnowReport2014.pdf
For fiscal year ending:
06/30/2014
REVENUE
Contributions and grants:
$538,209,000
Program service revenue:
$4,499,904,171
Investment income:
$225,489,000
Other revenue:
$18,498,829
Total revenue:
$5,282,101,000
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Wells Fargo-Jane Barsumian/Mary Lyons Trust
Boilerplate Language for Grant Applications
EXPENSES
Program services:
$3,495,990,331
Administration:
$75,821,255
Fundraising:
$51,683,802
Other expenses:
$1,083,136,612
Total expenses:
$4,706,632,000
Revenue less expenses:
$575,469,000
NET ASSETS OR FUND BALANCES
Total assets:
$11,710,607,000
Total liabilities:
$4,027,082,000
Net assets or fund balances:
$7,683,525,000
Additional finance-related comments (optional)
The aforementioned data reflects end-of-year numbers from the University’s Form 990 for the
fiscal year ending June 30, 2014.
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