Grant Application
Date:
____________________
Name of organization
Legal name, if different
Address
City, State, Zip
Employer Identification Number (EIN)
Phone
Fax
Website
Contact person
Title
Phone
Amount of grant: ________________
Focus Area: ____________________________ General operating support:
Email
Project/program support:
Additional Questions
This organization is an IRS 501(c)(3) nonprofit .
This organization is a public agency/unit of government.
We are using a fiscal agent:
Name: _______________________________ Fiscal EIN: _____________________________
Past SCAUW funding:
Year: _______________________________ Amount: _______________________________
Do you run a SCAUW campaign:
Yes: ____ No: ____
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Grant Application: Program Objectives
A. Program Narrative: Please explain your program logic or your “Theory of Change”
Please tell us a bit about your program logic.
1. What need(s) are you trying to address?
2. What short- and long-term impacts do you strive to make (outcomes)?
3. What strategies and tactics will you employ (activities)?
4. How will you measure your efforts (outputs)?
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A. Program Participants: Who will your program directly serve?
How many people do you anticipate serving in the SCAUW service area?
1.
2.
3.
4.
5.
6.
7.
Big Lake
Elk River
Otsego
Princeton
Santiago
Zimmerman
TOTAL
____
____
____
____
____
____
____
A.8. Program proportionality: Anticipated
a
b
c
Total
Amount of
% of Program
Program
SCAUW
you
Budget
Funding
anticipate will
Requested
be funded by
SCAUW
$
$
%
C=b/a*100
d
Total people
you expect to
serve*
e
Total
expenses per
participant
f
Total SCAUW
funding per
participant
#
$
$
E=a/d
f=e*c
g
Number of
participants who
reside in SCAUW
Service Area
h
Percent of program
participants who
reside in SCAUW
Service Area
%
From #7, above
h=g/d*100
*Participants are individuals, families or groups that are directly served by the program being funded by SCAUW (not by your organization in general).
Include participants both inside and outside the SCAUW service area.
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B. Program Components & Activities: What strategies will you employ or activities will you deliver as to create meaningful change?
What are your anticipated program activities? (Please list each in a separate row)
Number (How many times
will this activity be offered
during the grant period?)
1.a.
1.b.
2.a.
2.b.
3.a.
3.b.
4.a.
4.b.
5.a.
5.b.
6.a.
6.b.
How many people will you
serve for each activity?
1.c.
___Adult
___Youth
___Total
2.c.
___Adult
___Youth
___Total
3.c.
___Adult
___Youth
___Total
4.c.
___Adult
___Youth
___Total
5.c.
___Adult
___Youth
___Total
6.c.
___Adult
___Youth
___Total
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C. Outcomes: What meaningful impact or changes will your program create at the individual, household, school
and/or community level?
a. Please describe your program’s anticipated short-, mid- and
long- term outcomes.*
b. Who will be
impacted most
directly by this
outcome?**
c. How will you measure your impact?
Outcome 1:
__Short-term
__Mid-term
__Long-term
_ Individual
_ Household
_ Community
__Short-term
__Mid-term
__Long-term
_ Individual
_ Household
_ Community
__Short-term
__Mid-term
__Long-term
_ Individual
_ Household
_ Community
__Short-term
__Mid-term
__Long-term
_ Individual
_ Household
_ Community
Outcome 2:
Outcome 3:
Outcome 4:
*“Outcomes” are the key changes that your program endeavors to create in the communities you serve. Outcomes help us tell the story of
how programs are making a difference in the lives of the people we serve, as well as affecting the well-being of our communities as a whole.
**Applicants do not need to demonstrate impact in all three (3) categories. These categories are included to help illustrate the connection
between the outcomes you identify and the measurement strategy you will use.
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Authorization: Anti-Terrorism Compliance
Anti-Terrorism Compliance: In compliance with the USA PATRIOT ACT and other counterterrorism laws, Sherburne County Area United Way requires that
each agency/nonprofit certify the following:
“I hereby certify on the behalf of ____________________ [name of grantee] that all United Way funds and donations will be used in compliance with all
applicable anti-terrorist financing and asset control laws, statutes and executive orders.”
Name and title of Board Chair or Authorized Signer: ___________________________________________
Signature: _____________________________________________________________________________
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