Grant Application E-Mail Form

In order to be considered for funding, potential applicants must first contact Candace Medina (Executive Director) to establish eligibility and alignment of organizational missions.
Date of Application
Contact Information
Legal Name of Organization
Organization Address
City, State, Zip
Telephone
Fax
Website Address
Chief Staff Officer or Executive Director
Name
Telephone
Fax
Email Address
Contact Person / Project Director
Name (Required!)
Telephone
Fax
Email Address (Required!)
General Information
Year Founded
Federal Tax ID #
Geographic Area Served
People Served Annually
Mission Statement
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Objectives, Methodology, and Most Recent Accomplishments of Organization
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Is Organization listed as 'non-profit' with the Secretary of State?
Is Organization exempt under IRS 501(c)(3) guidelines (or earlier versions)?
Is Organization exempt under 509(a) guidelines (public charity)?
Is Organization legally affiliated with any other organizations?  Please List
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Funding Information
Fiscal Year Begins
Fiscal Year Ends
Annual Operating Budget
(current year)
Annual Operating Budget
(previous year)
If the organization was the recipient of funding from the agencies below, please list.
  Current Year Previous Year
Source $ Amt. % of Op. Budget $ Amt. % of Op. Budget
United Way
Federal Government
State Government
Local Government
Size and Source of 5 Largest Grants (other than the government and United Way grants above)
  Source Current Year Previous Year
1)
2)
3)
4)
5)
Organization Personnel
Number of full-time Employees
Number of part-time Employees
Number of Volunteers
Number of Directors on Board
Project Description
Grant Amount Requested
Briefly Describe the nature, scope and current status of the project:
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What need is addressed by this project, and what is the linkage to the goals of the organization?
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Who will benefit from this project?
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Are other groups providing similar services?
If yes, what distinguishes your project, or how does it complement others?
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Is this project being done in conjunction with (or in collaboration with) any other organization or non-profit group(s)?
If Yes, please list:
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What is the timing for this project?
Start Date
End Date
Project Evaluation
Describe the measurements that will be used to assess the success and effectiveness of the project, both short-term and long-term:
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Project Funding
Total project cost/budget:
Percent of year's budget:
List the funding from other private or public sources which has been received for this project, or which is under consideration.  List source, amount, and duration (i.e. start and end dates)
    Duration
Funding Source Amount Start (MM/YY) End (MM/YY)
Are there any matching or challenge grants associated with this project?
If Yes, please list
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Describe the plans for sustaining this project in future years (maintenance, etc.)
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Certification
Checking the box below and submitting this form certifies that the grantseeking organization retains its public charitable status according to it's online profile, and further certifies that this status is not in danger of being revoked.  In addition, certification affirms that the grantmaking organization has not received any goods or services in conjunction with this grant, and that all information is correct to the best knowledge of the submittor.
Certification
Certifying Officer's Name
Certifying Officer's Position
Required Attachments
  • Proof of 501 (c)3 status
  • Tax forms for past 3 years.
  • Income statements/balance sheets for past 3 years (audited, preferably).
  • List of Board members, titles, mailing addresses, phone numbers, and compensation (if applicable).
  • List of all financial contributors > $500.00 for the preceding fiscal year.
Mail To:
Candace G. Medina
Executive Director
The Gilbert Foundation
11805 Lake Stone Way
Prospect, Kentucky 40059