Grant Application Form

SUBMITTING YOUR PROPOSAL
Please do not use folders, notebooks or binders. Do not include videotapes or additional materials that are not specifically requested. Faxed proposals are not acceptable.

Scanned documents accompanying the proposal must be in .tif, .jpg, .bmp, or .pdf formats.

Note, if you currently have an open grant with The Hubbell-Waterman Foundation and plan to apply for a new grant for the same project, please be sure that you submit the required interim or final report for your current grant before applying again. If you have questions, contact C. D. Waterman III at 563-333-6608.

A cover letter accompanying your application is optional.

All fields are required

Applicant Organization (Legal Name):
Doing Business As:
Previous Name, if changed:
Street Address:
City/State/ZIP:
Phone:
Fax:
E-mail:
Web Site:
Executive Director:
Direct Phone:

Name as listed on IRS tax exempt determination letter:
IRS Letter Date:
Tax Exempt ID Number (EIN):

Organization Founded:
It's Mission Statement:
Number of Paid Staff (Full and part-time):
Number of Persons Served Annually:

Organization's Budget:
Revenue:
Expenses:
Organization's Endowment Size:

Organization's Five Major Funding Sources:
Organization's Geographical Focus:

Have you received funding from The Hubbell-Waterman Foundation in the past 3 years?	[] Yes [] No
If you answered YES please indicate total funding received:
Are you applying for an operational grant following construction of the capital improvement?	[] Yes [] No
Applicant is applying for the following type of grant that The Hubbell-Waterman Foundation has identified on its Statement of Priorities for the next annual funding cycle:

Program/Project Information related to this Grant Application/Request:
Type of grant requested:	[] Capital construction [] Operational Grant
Program/Project Title:
Total Cost of this Project:
Amount of Funding Requested:
Dates covered by this Grant:
Grant Request contact person:
Title:
Email:
Direct Phone:

Describe Current Services You Provide:
Please Summarize Proposed Purpose and Objectives of the Grant:
Is this a new or ongoing activity?

Brief description of the Program/Project:
Timetable for implementation:
Are other organizations participating? If so, who are they?
Brief demographic description of who will benefit from the Program/Project, including the number of adults/children who will be impacted and/or affected and how:
Community/Counties/Geographical Area served by Program/Project:

Evaluation
Expected results during funding period:
How do you define and measure success:

Do any trustees of The Hubbell-Waterman Foundation serve on your board of directors?	[] Yes [] No
If Yes, please list:

For this Application, please list below any other entities from whom you are requesting or may request funding, the amounts requested, and the amounts granted or otherwise committed:
Total amount being requested of The Hubbell-Waterman Foundation:	$
Others:
	$
	$
	$
	$
Total Funding Requests:	$
*Please note with an those requests that are still pending**

If you have received State or Federal Grants/Funding for this project, please list:
	$
	$
	$
	$
	$
Total:	$

Attachments - attach the following:

1. Board of Directors, occupations and/or community affiliations.

2. Antidiscrimination statement adopted by your Board.

3. List of names and qualifications of key staff.

4. Most recent fiscal year-end financial statement (audited if available).

5. Annual Report.

6. Program/project budget.

7. IRS tax exempt determination letter.

To attach documents from your computer, click "Browse" to locate a file on your computer. Once you have selected your file and clicked "Open" (or with some browsers "Select"), you will see the file listed below. You may delete any file from the list by clicking the delete button.

Scanned documents accompanying the proposal must be in .tif, .jpg, .bmp, or .pdf formats.

Please add any other comments you would like to make for the benefit of the trustees:
The undersigned hereby certifies that the information contained in this Grant Application/Request is correct to the best of our knowledge. We understand that our submission of this request does not guarantee funding will be provided in part or in whole. Please enter your initials and the current date in the boxes below.
Initials
Date