New Mexico Office of African American Affairs Request for Funding Proposal All requests should align with the mission of the New Mexico Office of African American Affairs which is to study, identify, and provide solutions to issues of concern relevant to the African American community. AWARDS All awards are contingent upon appropriations and funding availability. All information submitted will be reviewed by the Executive Advisory Committee to establish funding. The maximum amount of approved awards may not exceed $2,000. If there is a desire for increased funding for program delivery, contractual service agreements would need to be discussed with the Executive Director. Please Note: ***Incomplete proposals will not be considered. ***The New Mexico Office of African American Affairs must be listed as a sponsor on all marketing material in order to receive funding. ***Due to state procurement codes, all funding is processed on a reimbursement basis ONLY. ***Funding will not cover food or travel expenses. *Check One � Program or event supports one or more of the New Mexico Office of African American Affairs five focus areas: (*Circle All That Apply) Advocacy and Policy Educational Advancement Economic Empowerment Health Care Community Development � Juneteenth Programming Today’s Date: _______________________ Date of Event: ______________ Name of Organization/Program: ___________________________________________________ Address: ___________________________ City: ___________ State: NM Zip: __________ Contact Name: ______________________ Phone Number: ____________________________ Email: _____________________________ Amount Requested from OAAA $ _______________ Request for funding must be turned in for review at least two months in advance of event date. Revised 3/3/2015 POPULATION SERVED (demographics – indicate how many individuals served in each category; if applying for event funding enter prior year attendance data) Ages: ___ 0-5 ___46-55 ___ 6-11 ___56-65 ___12-15 ___ 66-75 Socio Economics: _____% Low-Income Gender: ____% female ___19-25 ___26-35 ___86-100+ ___36-45 _____% Middle-Income _____% Higher Income ____% male Race/Ethnicity: ___% African American ___% Native American ___16-18 ___76-85 ___% Caucasian ___% Hispanic/Latino ___% Asian ___% Other *Please Type or Print responses to the following on separate paper and submit with this Proposal ORGANIZATION AND MISSION Give a brief history of your organization or program. Make sure to include establishment date, mission, organization/program goals, history of service outcomes (number of individuals served, economic impact, major successes, etc…), program/event curriculum structure, and which New Mexico communities are impacted. (Max 200 words) COMMUNITY NEED Define the area of disparity addressing target audience, proof of need (statistics for your community), and expected outcomes. (Max 100 words) PROGRAM/EVENT OBJECTIVES Name who, what, when, where, and how the funding will assist your organization’s impact on achieving program/event objectives. Be sure to include the number of individuals whom will benefit from the program/event. (Max 100 words) OUTCOMES AND EVALUATION How will you measure the outcomes of the program/event to ensure objectives were met? Make sure they are measurable (pre-post survey, attendance records, improvement of collaborations and partners, increase in volunteer hours, economic impact, etc…..). (Max 50 words) SUSTAINABILITY OF PROJECT How will you insure that the program/event has a lasting, sustainable impact in the community? (Max 50 words) PUBLICITY How will you insure that the program/event is publicized for maximum attendance and has the acknowledgment of the New Mexico Office of African American Affairs as co-sponsor? (Max 50 words) Revised 3/3/2015 GOODS AND SERVICES List goods or services to be reimbursed with funding support from the New Mexico Office of African American Affairs. Note: Funding may not be reimbursed for certain categories (i.e., food, travel, and salaries). Only validated itemized receipts must be submitted for reimbursement – no written receipts will be accepted in lieu of originals. PARTNERS/REVENUE What community organizations, businesses, advocacy groups, etc., have you partnered with to accomplish other sources of funding? Is there any revenue coming from this event: auction, banquet, personal contributions etc.? Please list source and amount. OTHER SOURCES OF FUNDING AMOUNT $ Total $ BUDGET INFORMATION What expenses are related to Program/Event? Please list expenses, amount, and justification. LIST EXPENSES JUSTIFICATION AMOUNT $ Total $ Total Cost of Program/Event: ____________________________ VERIFICATION Have you ever received funding from OAAA or any other State Agency? Yes/No _____ If so what agency? ______________ Vendor #______________ or attach a State-Substitute W-9 or Federal W-9 Revised 3/3/2015 CERTIFICATION I certify that all information submitted in proposal is complete and is a true representation of all program/event services, objectives, outcomes, budget, and purpose of funding support. I also authorize the New Mexico Office of African American Affairs to utilize program information for public record, including but not limited to publicizing and reporting. I further understand that all awards are given on a reimbursement basis (after all duties have been performed or completed) and are subject to eligibility of approval (information in proposal must be complete and concise). All funding awards are contingent based on available appropriations. Signature: ____________________________ Date: ___________________ Printed Name: _________________________ Return completed Proposal Information to: Attn: Budget Analyst New Mexico Office of African American Affairs 1015 Tijeras NW, Suite 102 Albuquerque, NM 87102 Email: tanyam.ramirez@state.nm.us Fax: (505) 222-9489 Phone: (505) 222-9405 _________________________________________________________________________________ Agency Use Only This Funding Request for $_______________ has been approved in the amount of $_____________ Revised 3/3/2015