Alice Huffard Richards Leadership Grant Application ← Community Foundation of West Georgia

I. Organization Information

Application Date

Name*

Organization's Name

Phone*

Email*

Address*

Street Address City State ZIP Code

II. GRANT DETAILS

Type of Grant*

III. Program / Project Details

Amount Requested*

(X,XXX.XX) No $ required.

If the request is partially funded, will the project/program still be viable?*

Yes
No

Total Current Operating Budget*

(X,XXX.XX) No $ required.

Sources of Finanical Support

Please list your sources of financial support (not including AHR), noting the type and percentage of the support. Example: CFWG, grant 15% (List each 2015 Grantor and grant); 5-K race 30% and memberships 25%, Annual campaign %, Earned Revenue Sources if applicable %. Other (specify) %.

Total Program Budget*

(X,XXX.XX) No $ required.

Program Budget Summary*

Please provide a detailed summary of how the funds for your project or program will be allocated, emphasizing how and where the funds granted from AHR will be utilized. Be specific with all expenses, break down where the AHR money will be applied (i.e. operational expenses, programmatic expenses) and include other anticipated sources of support for the program. Use this field to give a budget summary and the field below to attach a spreadsheet of budget.

Attach Budget HERE

Projected Program Start Date*

Program Title*

Type of Request*

General Support
Program Support
Operational Expenses
Other

What counties will this program serve?*

Carroll
Haralson
Heard

Project/Program Narrative*

Describe the problem/opportunity that the AHR grant will address in a brief narrative. Explain how a grant from the AHR fund would impact this. Emphasize how and where funds granted by AHR will impact AHR’s stated impact intentions for the environment. Limit your response to a minimum of 800 words and a maximum of 1500 words. Please include the following in your explanation: * Specifically, what is the problem or opportunity to be addressed and how will the grant address the problem/opportunity? * What are the goals/objectives of the program? How will they be measured? * Who are the targeted groups that will benefit?. * How is your request aligned with the AHR Fund's grant making priorities. * Identify in your narrative collaborations or partnerships with other groups to accomplish your goal(s).

IV. Measurement & Reporting

What data do you gather to evaluate the impact of your work associated with this grant?

What will you (specifically) measure and report to AHR to evaluate the success/status of this program or project?

V. Organizational Structure

Do you have 501(c)(3) certification?*

No
Yes
Not Applicable

Please attach copy of 501(c)(3) certification*

Please note date 501(c)(3) certification acquired

Federal Tax #ID*

Date Incorporated*

Describe any recent accomplishments of the organization in Carroll, Heard, Haralson Counties: those served, impact made, local partners/stakeholders.*

Limit your response to 600 words.

Please list the current Board of Directors, including their address and occupations:*

Please list the organizations current staff with titles.*

Number of paid employees*

Number of volunteers*

Has your organization participated in any of the AHR Fund's Nonprofit Capacity Building program offerings?*

Yes
No

Please indicate the program offering(s) below:*

2014 AHR Nonprofit Leadership Institute (AHRNLI) graduate
2014 AHRNLI Mini-Grant Recipient
2015 Board Bulding / Boot Camp Participant

If Other - please explain.

VI. Financial Information

Has your organization received an AHR Grant before?*

No
Yes

Please list year(s) and program/purpose for AHR Grants received by your organization. Do not list any other grants received from CFWG.*

Include the year, amount and purpose of the grant.

VII. Collaborating Partners

Please attach a one page letter of support from any partners directly collaborating in the project/program for which you are requesting funding.