2016-02-12
GRANTS TO ORGANIZATIONS FY2014
RESIDENCY INCUBATOR APPLICATION FORM
Do not staple or bind the application or support materials.
A
APPLICANT INFORMATION
Organization Name:
Address:
Web Site:
Org Phone:
www.
Fax:
Federal ID No. (EIN):
Elected Official District Information for Organization:
Date Incorporated:
City Council:
Date of IRS Ruling:
County Commissioner:
Project Contact:
E-mail:
Contact Person Title:
Phone:
Name of CEO or Executive
Director (ED):
E-mail:
Official Title of CEO:
Phone:
Board Chair:
Address:
(other than
organization)
B
ext.
ext.
E-mail:
Phone:
Fax:
ASSURANCES
The authorized officials signing these assurances certify the following:
1.
2.
3.
4.
5.
6.
The Applicant Organization is a non-profit organization, duly incorporated in the State of Texas, with a functioning board of
directors and bylaws.
The Applicant Organization is classified by the U.S. Internal Revenue Service, under Section 501(c)(3) of the IRS Code, as a
nonprofit, tax-exempt organization donations to which are deductible as charitable contributions under section 170(c)(2)
and that the IRS determination is current.
The applicant has read, understands and will conform to the policies and regulations of the Grant Program of the Houston
Arts Alliance, as published in the 2013 Grants for Organizations program guidelines.
The applicant organization is responsible for the programs and services for which grant support is sought. Any funds
received as a result of this application will be used solely for the purposes described in the application.
The applicant is in compliance with all applicable federal, state and local laws.
Applicants awarded grants funded with Hotel Occupancy Tax agree to spend the grant funds only for purposes permitted by
the Texas Tax Code Chapter 351.
The application submitted to Houston Arts Alliance has been duly authorized by two authorized officials for the applicant organization. At
least one of the authorized officials is a principal of the organization with the legal authority to certify the information contained in the
application and sign contracts for the organization. Signers must not be related.
SIGNATURE # 1
Signature of Executive Staff
Print Name:
Title:
SIGNATURE # 2
Date
Signature of Board Chair
Print Name:
Title:
Date
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C
STAFF LEADERSHIP
1.
The organization’s Executive Director or CEO is:
Full Time
Part Time
Paid
Unpaid
2.
3.
The organization’s Artistic Director (AD) is:
Number of staff who are:
Full Time
Part Time
Paid
Unpaid
4.
Full Time
Part Time
Total Number of paid staff:
5.
Tenure of Current Executive Director:
D
Contractual
Interns
= # full time + # part time + # contractual
Years
No AD
Volunteers (Unpaid)
| Tenure of Previous Executive Director:
Years
BOARD LEADERSHIP
Race/Ethnicity
Full Board
1.
African American
2.
Asian American
3.
Latino / Hispanic
4.
Native American
5.
Caucasian
6.
Multi-Racial
TOTALS
7.
8.
Board of Directors Gender Ratio
# of Males
# of Females
Of your Full Board Members, how many participated in a formal board contribution during the current term:
9.
Frequency of Board Meetings:
E
monthly
bi-monthly
quarterly
of
other:
FACILITY INFORMATION
Administrative /
Office Space
Check the
Administrative
Equipment the
organization has
access to:
Space for Artistic
Programs
(Performances,
Exhibits, etc.)
Own
Lease Commercial Office Space
Donated Commercial Office Space
Donated Residential Office Space (Administrative offices at CEO, Artistic Director or Board Member Home)
No Administrative Offices
Other (please explain:
Telephone
Answering system
Copier
Fax Machine
Computer and Printer – Number of each
Internet Access:
wireless
Broadband
T-1/T-3 dedicated lines
Scanner
Accounting/bookkeeping system:
If checked, which software:
Excel
QuickBooks Other (please fill name):
Contact Management System:
If checked, which software:
Constant Contact
Patron Mail
Traditional Email
Other (please fill name):
Own
Lease or Rent Space for long-term
Lease or Rent various spaces depending on the artistic program
Donated Space
All programs are outreach at other organization’s locations
Other (please explain:
If you lease space for artistic programs, please list the location(s):
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F
LEADERSHIP TEAM
Leadership Team members will support the Primary Contact to meet all participation requirements of the program.
Authorization Form for participation requirements.
See
Please list the board and staff members that the organization has designated to be part of the Leadership Team (leave the column
blank if the information is not applicable for the person). Briefly describe below the rationale for the selection of this team. Attach a
separate page if needed. List up to 5 members.
Leadership Team Members
Staff
Years Working
Board
Years Serving on
Position
on Staff
Position
the Board
Full Name:
Email:
Full Name:
Email:
Full Name:
Email:
Full Name:
Email:
Full Name:
Email:
Rationale for Team Selection (200 word limit):
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G
FINANCIAL MANAGEMENT INFORMATION
1. Method of accounting:
Cash
Accrual
2. IRS Form 990’s posted on Guidestar:
2010
2011
2012
If filing(s) not posted on Guidestar, attach signed hard copy filing as Supplemental Material.
3. Organization prepares the following financial statements for board review in the following frequency:
Statement of Financial Position (balance sheet):
Monthly
Quarterly
Annually
other: __________
Statement of Activities (income statement):
Monthly
Quarterly
Annually
other: __________
Statement of Cash Flow:
Monthly
Quarterly
Annually
other: __________
4. Organizational Budget of current fiscal year approved by the Board of Directors on (MM/YYYY):
5. Complete the Financial Profile spreadsheet. Submit the completed EXCEL spreadsheet to jerome@haatx.com by deadline.
Access the Financial Profile spreadsheet on the HAA website: : http://www.houstonartsalliance.com/programs/programs/
Section G Addendum: Organization Financial Information
You may include a brief statement to clarify points regarding the financial history of your organization on Section F. Please limit
your statement to this page only. If you wish not to include a brief statement, please leave this page blank.
Organization Name: ____________________________________
(Begin statement here.)
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H
NARRATIVE: WHAT STAGE ARE YOU IN YOUR LIFECYCLE?
With time and experience, organizations
travel through seven (7) stages of an
organization’s lifecyle. Relevant programs
and critial infrastruture are needed to
move from one level to the next.
Experience
Directions to respond in the next page:
a) For each Section, chose one Stage # that
best reflects your org’s current status.
b) Respond with specific challenges you are
facing and how it can be addressed.
Time
Section I : Program Stages:
1.
2.
3.
separate its
4.
5.
IDEA (I):
Programs are not defined, only an intense, personal mandate to fill an artistic gap in Houston.
START-UP (S): Programs are simple, experimental, and generally have more breath than depth.
GROWTH (G): Organization begins to understand and define the distinctive methods and approach that
programming from others.
MATURITY (M):
Programs are well-organized; results focused; and in touch with community needs.
DECLINE (D): Programs are losing audiences to others whose approach is more accessible, and possibly less
expensive.
6.
TURNAROUND (T):
Programs are reassessed and modified in light of current market needs and financial
viability.
7.
TERMINAL (X): Programs are unreliable, unsteady, and seriously under-funded.
Section II : Board Governance Stages:
Section III: Financial Resources Stages:
1.
(I)
No board exists at this stage, only supporters
with a personal connection to mission.
2. (S)
Members almost always have a personal connection
to mission or founder, yet roles & responsibilities are
undefined.
3. (G)
Board structure begins to appear, especially in
meetings, reporting, and committees.
4. (M) Board sets direction, is policy oriented and leaves
management to the executive director.
5. (D)
Board is unaware there is something wrong; they
think things are running smoothly and often don’t
take action until money starts running out.
6. (T)
A core of committed board members is ready to do
what it takes to restore organizational integrity.
7. (X)
Board has lost its collective drive to continue and may
exist in name only.
1. (I)
Section IV: Management Stages:
Section V: Administrative Systems Stages:
1. (I)
1. (I)
2. (S)
3. (G)
4. (M)
5. (D)
6. (T)
7. (X)
Founders are believable, action-oriented people
with commitment to proposed purpose.
Leader is a “spark-plug” and the group’s most
experienced staff person (who is mostly unpaid).
Organization is led by part-time staff/board who see
infinite potential for programming.
Executive leadership is formed & compensated; often
second or third generation from the originators.
Organizational slippage is either unseen, denied, or
blamed for external sources.
Turnaround leader is a gutsy, strong-willed person
with clear sense of direction and ability to inspire
confidence in others.
Staff and management have dwindled to a handful
2. (S)
3. (G)
4. (M)
5. (D)
6. (T)
7. (X)
2. (S)
3. (G)
4. (M)
5. (T)
6. (X)
Sweat equity is the usual self-funding device, unless
originators have deep pockets or an outside “angel”
backs the project.
Usually a low-budget, boot strap operation unless seeded
initially by a major start-up grant.
More sources of income create greater accounting and
compliance complexities.
Organization has multiple sources of income and is not
dependent on one source of funding.
Budgets are fixed-cost and expense heavy, with income
projections reflecting past experience rather than reality.
Willingness to cut expenses to reflect realistic income
and cash flow.
The organization is most likely out of money and may
have accumulated deficits.
Although generally lacking in systems, in-kind services,
equipment and other goods may exist.
Financial and administrative functions and systems are
generally weak and may be out-sourced to others.
Current systems, never good to begin with, must now be
substantially improved to meet the demand of continual
program expansion and rising compliance.
Organization operates from an outlined course of
actions/policies/procedures for routine client, board, and
personnel matters.
Systems, although developed, are often antiquated, and
physical space may be deteriorating.
Existing policies and procedures may be too complex,
expensive, and “mature” for the turnaround
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and possibly may be working without pay.
H
organization.
NARRATIVE: WHAT STAGE ARE YOU IN YOUR LIFECYCLE?
Check off:
early stage (just starting)
mid stage
late stage (well ingrained)
Response: What specific challenges are you experiencing area? What does success look like by September 30, 2016 as we address
these issues through the Residency Incubator program? (100 – 150 words max)
I. Programs:
Stage #
II. Board
Governance:
Stage #
Check off:
early stage (just starting)
mid stage
late stage (well ingrained)
Response: What specific challenges are you experiencing area? What does success look like by September 30, 2016 as we address
these issues through the Residency Incubator program? (100 – 150 words max)
III. Financial
Resources:
Stage #
Check off:
early stage (just starting)
mid stage
late stage (well ingrained)
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Response: What specific challenges are you experiencing area? What does success look like by September 30, 2016 as we address
these issues through the Residency Incubator program? (100 – 150 words max)
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H
NARRATIVE: WHAT STAGE ARE YOU IN YOUR LIFECYCLE?
Check off:
early stage (just starting)
mid stage
late stage (well ingrained)
Response: What specific challenges are you experiencing area? What does success look like by September 30, 2016 as we address
these issues through the Residency Incubator program? (100 – 150 words max)
IV. Management:
Stage #
V. Administrative
Systems
Stage #
Check off:
early stage (just starting)
mid stage
late stage (well ingrained)
Response: What specific challenges are you experiencing area? What does success look like by September 30, 2016 as we address
these issues through the Residency Incubator program? (100 – 150 words max)
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I
SUPPLEMENTAL & ARTISTIC MATERIALS
Compile the following documents for both HARD COPY and ELECTRONIC COPY Supplemental Materials:
1.
HARD COPY SUPPLEMENTAL MATERIALS: KEEP MATERIALS IN THE ORDER BELOW. ONE COPY SET. NO
STAPLES. SLIP SHEET EACH SECTION W/ ONE COLOR PAPER.
Assurances Page (with original authorized signatures).
One to two page history of the organization, including its board & staff management history.
Resume and organization job description of the CEO or Executive Director.
Organizational chart with staff and board (officers, committee chair) designations.
Board Composition Matrix. Obtain the template at the P&S Guidelines & Applications webpage.
Current Year Annual Operating Budget as approved by the Board of Directors.
Both Prior Year and Year to Date (YTD) Statement of Activities (Income / Profit & Loss Statement). Please include the following
columns [ Budgeted | Actual | Variance (+/-) ].
Both Prior Year and Year to Date (YTD) Balance Sheet.
Copies of signed IRS Form 990 Annual Tax Filings NOT POSTED ON GUIDESTAR as reported in Section G. If 2010 – 2012 filings
are on Guidestar, you do not need to submit hard copies as a Supplemental Material. To access your IRS Form 990, log onto
www.guidestar.com. If you have further difficulties downloading your Form 990, you can request your forms from HAA Staff
Jerome Vielman at jerome@haatx.com.
Agendas and minutes from the last three (3) Board of Directors Meetings.
Most current Organizational Board Bylaws.
ARTISTIC SUPPORT MATERIALS:
1 copy of the list of the CURRENT season (2012-2013) of arts or cultural performances, exhibitions, activities or programs that
were/are open to the public with the date, title of the activity, and venue/location.
1 copy of the list of the NEXT season (2013-2014) of arts or cultural performances, exhibitions, activities or programs that
were/are open to the public with the date, title of the activity, and venue/location.
1 set of Artistic Support Materials, which should be an appropriate combination of CD/DVD, books or printed materials (1 set
including: programs, flyers, press clippings, press releases, etc, - no posters), as applicable to your artistic discipline or project.
You are advised to check copies of electronic materials prior to submission. As panelists may not be familiar with your
organization, the quality of the materials you submit may reflect upon the quality of your programs.

2.
If you have video posted online, provide an additional page listing at most 3 web links that the panel can view your work.
ELECTRONIC COPY SUPPLEMENTAL MATERIALS:
At deadline date, submit to Jerome Vielman, Programs & Services Manager, the completed templates via email to jerome@haatx.com.
Access these templates via online at http://www.houstonartsalliance.com/programs/programs/ .
Board Composition Matrix. Obtain a file at the P&S Guidelines & Applications webpage.
Section G - Financial Profile spreadsheet. Obtain the template at the P&S Guidelines & Applications webpage.
3.
COMPLETE THE FOLLOWING SURVEY:
Organizational Assessment Survey. Must be completed by full Leadership Team (see Section F).
Complete the survey at http://www.surveymonkey.com/s/modesurvey or by clicking here.
Hand Deliver unbound materials by 5:00PM Friday, May 3, 2013 or
Mail unbound materials by postmark date Wednesday, May 1, 2013 to:
Houston Arts Alliance | 3201 Allen Parkway, Suite 250 | Houston, TX 77019–1800
Attn: CBI – Residency Incubator Program
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