2023 Grant Application Form Grant Application Multi-Page Step 1 of 3 0% General InformationToday's Date* MM slash DD slash YYYY Organization Name* Legal Name Address* Street Address PO Box (if applicable) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Grant Contact Person* First Last Title (Note: Does not need to be same person signing the application.)Phone*Email* Year Agency Established*Mission Statement*Current Services/Programs*Brief description of the core services/programs your organization offers to its clients. (750-character maximum)Total Number of Agency Clients Served Annually*Number of Full-Time Equivalent Employees*Number of Volunteers Directly Associated With Program/Project to be Funded*Electronic Signature* First Last Title By submitting your name, you attest that the information contained in this application is complete and accurate. (Must be signed by supervisory staff member or Board of Directors' president/chairperson of the organization's governing body.) Grant DetailsName of Project/Program to be Funded*Amount Requested (cannot exceed $2,500)*Purpose of Grant*Existing Program/ProjectNew Program/ProjectTechnical AssistanceStaff EnhancementChoose one option that best describes your grant request's purpose.Area of Funding Priority* Economic Self-Suffiency Education Health and Well-Being Leadership Development Safety, Dignity, and Freedom From Violence (Please check all that apply.)Program/Project Summary*(50-word maximum)Where is your program/project offered?*Some programs/projects operate out of multiple locations. Please identify the primary location address of your program/project and any satellite locations, if applicable.Does your program/project have any collaborating partners?* Yes No Collaborating partners are any other agency working with you to provide services with your clients. Please be sure you're noting your collaborations, as we view these as highly beneficial to the merits of your grant request.If you answered "yes" to the previous question on collaborating partners, please list those partners here by name and address.(If no collaborators, skip this question.)Focus/Funding PrioritiesPlease answer the following questions as they relate to your program/project's focus on females and/or the FDLA Women's Fund's funding priorities. (Each question is limited to 750 to 1,000 characters.)How is this program/project designed to primarily benefit Fond du Lac County women and/or girls?*How does this program/project address at least one funding priority?*Goals, Objectives and OutcomesList no more than three program/project goals with accompanying outcomes and method of measuring success.Goal 1*Goal is defined as: The big picture. What do you want to get out of this project/program?Goal 1 Objective(s)*Objective is defined as: The method you plan to use to achieve your goal. What steps will you take to meet the goal?Goal 1 Outcome*Outcome is defined as: The measurable success that occurs. Be sure not only to identify the outcome, but also address what strategies/methods will be used to evaluate the success of your project/program? And who will be involved in evaluating your project/program success?Goal 2(Note: If your program/project does not have a another goal, skip this section.)Goal 2 Objective(s)Goal 2 OutcomeGoal 3(Note: If your program/project does not have a another goal, skip this section.)Goal 3 Objective(s)Goal 3 OutcomeTarget PopulationPlease answer the following questions as to what population(s) your program/project will benefit annually.What is the anticipated total number of participants to be served directly by your project/program annually?*How many female-identifying idividuals will make up the annual program/project total served directly?*How many male-identifying individuals will make up the annual program/project total served directly?*How many female-identifying individuals will make up the annual program/project total served indirectly?*These are not direct clients, but perhaps others associated to the client (family members, for example) who will have an indirect benefit by your work with the client. Please note: You will need a way to track this number on your evaluation tool(s).Breakdown of female-identifying individuals served by age?*Please use the following age breakdowns to describe how many women and/or girls you anticipate serving annually through your program/project: Number of Girls infant to 11 years old; Number of Girls 12 to 17 years; Number of Women 18 to 24 years; Number of Women 25 to 39 years; Number of Women 40 to 54 years; Number of Women 55 and older. If your program/project does not serve women/girls, please explain why and give age demographics for men/boys in the same category breakdowns described above.Breakdown of female-identifying individuals served by race/ethnicity?*Please use the following race/ethnicity categories to describe how many women and/or girls you anticipate serving annually through your program/project: American Indian/Native American; Asian or Pacific Islander; Black/African American; Hispanic/Latina; White/Caucasian; Multiracial; Unknown. If your program/project does not serve women/girls, please explain why and give race/ethnicity demographics for men/boys in the same category breakdowns described above.Breakdown of female-identifying individuals served from a socioeconomic standpoint*Please use 2021 U.S. Federal Poverty Guidelines to frame your answer. https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references/2021-poverty-guidelines#guidelines If your program/project does not serve women/girls, please explain why and give socioeconomic demographics for men/boys in the same category breakdowns described above.List names of the Board of Directors*Names can be separated by a comma Required AttachmentsPlease upload the following attachments to complete your application.Program/Project Budget*Max. file size: 50 MB. Must use the budget form that is downloadable from the Grants page on our Website (no exceptions).Current Year (2022) Agency Budget*Max. file size: 50 MB. Most Recent Past Fiscal Year Profit & Loss Statement*Max. file size: 50 MB. If fiscal year coincides with calendar year, this would be P&L as of Dec. 31, 2022.IRS 501(c)3 Letter of Determination*Max. file size: 50 MB. Board of Directors & Affiliations*Max. file size: 50 MB. CAPTCHAFinal Review* Yes, I'm ready to submit! Note: Once you have submitted your application, no further changes can be made to your application. Posted on December 20, 2022 By: Sarah Ninmer Uncategorized