The Dana Home Foundation Program Grant Application 2017

• Gather the information requested below.
• Save the information (including questions) in a .pdf format.

Applicant and Program Information

1. Organization’s Name          
2. Program Name        
3. Grant Amount Requested  
4. Total Budget for Program
5. Brief Summary of Program
6. Does organization have IRS 501(c)(3) status? (if so, skip to question 8)
7. Is applicant a municipal or other US governmental entity intending to use the funds solely for charitable purposes?
8. Were previous grants received from The Dana Home Foundation within the last five years? 
9. Primary contact name (person able to answer questions and/or provide additional information about Part I of the Grant Application.)
10. Primary contact email address
11. Primary contact telephone
12. Describe anticipated program timeline including anticipated program starting date and program completion date, if applicable
13. Provide a detailed one-page summary of the proposed program’s total budget that includes:
    a.   An itemized list of projected expenses; and
    b.   All sources of funding for this program (and the amount anticipated from each source).
14. If you anticipate this program continuing beyond this grant year, please specify how you plan to continue funding the program.
15. Describe program funding and success in previous years. (If this is a new program, state so.)
16. State program goals and objectives and describe your plan to meet these goals and objectives.
17. Describe your plan to measure your achievement of program goals.
18. Describe the target audience of the program.
19. Provide anticipated number of seniors served by program and describe the seniors’ connection to Lexington.
20. List any other organizations/departments you are collaborating with to accomplish the program.
21. Describe any additional approvals needed for program. 

Financial Information

    22.   Name of head of organization
    23.   Mailing address of organization
    24.   Office telephone number
    25.   A copy of organization’s IRS 501(c)(3) determination letter, if applicable
    26.   Tax ID number
    27.   Total number of paid staff
    28.   Total number of volunteers
    29.  A list of the organization’s Board of Directors, if any.
    30.  Year organization was founded
    31.   Fiscal year end date
    32.  Annual operating budget
    33.  Does organization receive funds from any government agency? (If not, skip to question 32)
    34.  Describe funds received from any federal, state, or local government agency, if applicable.
    35.  The organization’s current balance sheet
    36.  The organization’s most recent available quarterly income statements
    37.  If the organization has been in existence for less than three years, please provide the organization’s operating budget for the previous year.
    38.  Provide letters of support or approval from any government departments or agencies if  needed in order to proceed with the proposed program.

 Please note that the Dana Home Foundation reserves the right to request additional financial information from the applicant during the application review process.