African American Unity Fund

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Application Cover Page

Application Date *

Federal Tax ID # *

Organization Type *

Agency Focus *

Year agency (or program) started operating *

Use this space to provide information for your organization. Please use regular capitalization (not all capital letters).

Organization Name *

Name of Executive Director/CEO *

Primary Contact Salutation * This is the primary contact person for this proposal in case of any questions or follow-up.

Primary Contact First Name *

Primary Contact Last Name *

Primary Contact Suffix

Primary Contact Title *

Mailing Street *

Mailing City *

Mailing State/Province *

Mailing Zip/Postal Code *

Phone *

Fax

Email *

Website

Use this space to provide information ONLY if you marked "not a 501(c)(3)" and are applying for funds through a fiscal agent.

Fiscal Agent Name

Fiscal Agent Contact Person

Fiscal Agent Contact Person Title

Fiscal Agent Mailing Address

Fiscal Agent Phone

Fiscal Agent Email

Fiscal Agent Fax

Fiscal Agent Website

Fiscal Agent ED/CEO

Typed Signature of Fiscal Agent

Proposed Program Focus: *

Please give no more than a two-sentence summary of request (no more than 500 characters and spaces): *

Dollar Amount Requested * For this and all other dollar amounts, type whole numbers only (5000, for example, not 5,000 or 5000.00). Do not include dollar signs ($).

Total Project Cost *

What was the last African American Unity Fund grant your agency received?

Last Grant Amount

Last Grant Date

Last Grant Purpose

I have read the guidelines for this African American Unity Fund Grant Application. I understand that not all funders use this format.

Typed Signature *

Date of Signature *

African American Unity Fund Grant Application

Please note that each text box allows for 1000 characters and spaces.

Organizational description *

Purpose of grant request *

Strategies: What actions will you take to implement this program? *

Results: Expected results for your agency, the people it serves, and our community *

Evaluation: How will you know if this program is successful? *

Sustainability: how will you continue this program beyond the grant period? *

Similar Organizations or Programs: List some other organizations that offer similar services. Discuss how services are coordinated and if any gaps remain. *

How many clients does your organization serve in a year? *

How many clients would this grant serve? *

For the following questions, consider the populations your organization currently serves.

Please enter what percentage of your clients are in each of the following identity groups:

African American Clients *

Asian American Clients *

Caucasian Clients *

Latino/Latina Clients *

Native American Clients *

Asian Clients *

African Clients *

Other Client Type

Other Client (Percentage) *

Total Clients (This will sum automatically from the values above and must equal 100%)

Check all of the populations that your organization currently serves. (Choose all that apply. Hold down the "CRTL" key to select more than one.) *

Check your organization’s geographic areas of service (choose all that apply. Hold down the "CRTL" key to select more than one.) *

Financial Information. Please use the budget templates below. The left-hand column is your organizational budget, and the right-hand column is the budget for your proposed project.

Income: Current Fiscal Year Ending *

Govt Grants/Contracts: Org *

Govt Grants/Contracts: Project *

Pending Foundation Requests: Org *

Pending Foundation Requests: Project *

Please specify amounts and funders of pending requests

Confirmed Foundation Requests: Org *

Confirmed Foundation Requests: Project *

Please specify amounts and funders of confirmed requests

Corporations: Organization *

Corporations: Project *

United Way/Federated campaigns: Org *

United Way/Federated campaigns: Project *

Individual Contributions: Organization *

Individual Contributions: Project *

Membership/Fee Income: Organization *

Membership/Fee Income: Project *

Investment Income: Organization *

Investment Income: Project *

In-Kind Income: Organization *

In-Kind Income: Project *

Other Income: Organization *

Other Income: Project *

Other Income: Org (Please describe):

Other Income: Project (Please describe):

Total Income: Organization

Total Income: Project

Expenses (Current Fiscal Year)

Salaries/Wages: Organization *

Salaries/Wages: Project *

Insurance/Benefits/Taxes: Organization *

Insurance/Benefits/Taxes: Project *

Consultants/Professional Fees: Organization *

Consultants/Prof Fees: Project *

Travel: Organization *

Travel: Project *

Equipment: Organization *

Equipment: Project *

Supplies: Organization *

Supplies: Project *

Printing/Copying: Organization *

Printing/Copying: Project *

Telephone/Internet: Organization *

Telephone/Internet: Project *

Postage: Organization *

Postage: Project *

Rent/Utilities: Organization *

Rent/Utilities: Project *

Depreciation: Organization *

Depreciation: Project *

In-Kind Expense: Organization *

In-Kind Expense: Project *

Other Expense: Organization *

Other Expense: Project *

Other Expense: Organization (Please describe):

Other Expense: Project (Please describe):

Total Expenses: Organization

Total Expenses: Project

Board and Staff Information

Current Board Members: Please list name; officer role served on your board, if any; and professional affiliation (employer and title) *

What percentage of your agency's board is African American? *

What percentage of your agency's front-line staff is African American? *

What percentage of your agency's management staff is African American? *

After you press the "Submit" button below, you will have a chance to review your complete application, go back and make changes, and print a copy for your records. You must then press the "Confirm" button (at the bottom of the next page) to complete your submission, and you will receive a confirmation email after it is submitted successfully.

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