FY 2019 Community Collaboration Grant Application

Community Collaboration Grant Applicant

Applicants MUST be a SELCO member to qualify for Community Collaborations grant funds.

As part of the Legacy Amendment requirements, the applicant and organizational information will be posted on the State of Minnesota's public Legacy webpage.

Member Library

Project Coordinator

Library Director

Mailing Address

City

Zip Code

County

Email

Phone

Federal 9-Digit EIN (Tax ID)

Project Details

ACHF Library Legacy Category

Arts Access/Education/Outreach - visual, performing, media, literary, and interdisciplinary art forms.Cultural Heritage Preservation - values and traditions that serve to identify us collectively as MinnesotansHistoric Preservation/Education/Outreach - preserving the evidence and telling the stories of human habitation and culture in Minnesota

Project Name

Project Description - Please provide an overall description of your project. Activities/Events will be listed below.

Project Program/Event

If there are multiple public program/event, you must list every date. For example, if the same musician performs 4 different times, each must be listed as its own activity/event.

If there are any changes, additions, or cancellations of dates, you must notify SELCO prior to the change.

Program/Event - Title and Short Description

This includes title and a short description of the activity/event.

Date of Program/Event or Range for a Continuous Event (exhibit, etc.)

Time of Program/Event (if known)

Location of Program/Event

Location Name

Address

City

ZIP Code

County

Measurement Methods- How are you going to evaluate the expected outcomes: survey, interviews, etc.?

Expected Outcome Goals- They must be measurable. Who is your target audience? What is the change in knowledge, skills, abilities, and/or life situation expected as a result of the program? How will you determine the project to be a success?

Partnership

SELCO requires the involvement of at least one community partner for the successful completion of a Community Collaboration application and project.

Any organization, group or individual donating time, money or effort to your grant project must be listed as a partner. Each partner must submit a letter of support acknowledging awareness of this application and confirming any pledges of support stated within. Letters of support are due concurrent with your application materials.

Electronic copies may be submitted to legacy@selco.info.

Partner

Partner Organization/Person

Contact Information for Partner - Example "Josie Doe, jdoe@selco.info"

Partner Role (In-Kind donations or additional funding for the project must be listed in the budget section of the application.)

What is your partner supplying in this? Space? Advertising? Money?

SELCO use only

Letter of Support

Yes

Date Received

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Budget

The limit for Community Collaboration projects is $7,000 per library per grant.

If your project is for more than $7,000 please contact the SELCO Legacy Project Coordinator at legacy@selco.info before submitting your application.

Please round amounts up to nearest dollar. ($135.03 becomes $136)

This form is now able to do auto-fill and auto-calculations. Please, still double-check your numbers!

Grant Request Budget

	Amount Requested
a. Contracted Services (artist payment, travel, hotel) *W-9 required	$
b. Advertising/Marketing	$
c. Technology/equipment	$
d. Materials (consumables)	$ Expenses for consumables used in the course of the program, exhibit or project. The applicant or partners cannot claim expenses for prizes or incentives, including refreshments.
e. Evaluation	$ Expenses related directly to measuring outcomes used in the final report.
f. Miscellaneous (include description below)	$ No food or beverages
SUB-TOTAL	$
g. Collection (10% max of the subtotal)	$
TOTAL	$

*If SELCO is paying these expenses directly to the performer, speaker, etc., they must fill out a W-9 form to be returned to SELCO.

Grant Request Budget Narrative

a. Contracted Services (honorarium, travel, hotel)

b. Advertising/Marketing

c. Technology/Equipment

d. Materials (consumables)

e. Evaluation

f. Miscellaneous

g. Collection - may not account for more than 10% of the Grant Requested Budget

Receipts and invoices may be turned in at any time during the grant project. All receipts and invoices must be in when the final report is submitted.

Applicant agrees to submit all receipts or invoices.

Fiscal Agent

I understand that SELCO will serve as fiscal agent for this grant on behalf of the applicant.

In-Kind Contributions-Member Library

In-Kind expenses are those that will not be paid for from Legacy funding. While they may include monetary contributions, other services and resources should be included as well. These may include the amount discounted by a vendor, the estimated cost of renting a location that has been donated, and the amount of staff time spent on creating and evaluating the program multiplied by wage.

	In-Kind Amount
a. Personnel (coordination & development by member library and/or contracted services)	$
b. Advertising/marketing of program	$
c. Technology/equipment	$
d. Materials (consumables)	$ Expenses for consumables used in the course of the program, exhibit or project.
e. Evaluation	$ Expenses related directly to measuring outcomes used in the final report.
f. Miscellaneous (include description below)	$
g. Collection	$
TOTAL	$

In-Kind Narrative - Member Library

a. Personnel - estimated time/hourly expense of library staff time used for the coordination and execution of the Community Collaboration program.

b. Advertising/Marketing

c. Technology/Equipment

d. Materials (consumables)

e. Evaluation

f. Miscellaneous

g. Collection

In-Kind Contributions-Partner

In-Kind expenses are those that will not be paid for from Legacy funding. While they may include monetary contributions, other services and resources should be included as well. These may include the amount discounted by a vendor, the estimated cost of renting a location that has been donated, and the amount of staff time spent on creating and evaluating the program multiplied by wage.

List each partner it its own In-Kind section.

Partner Organization/Person

	In-Kind (Partner)
a. Personnel (coordination and development and/or contracted services)	$
b. Advertising/marketing of program	$
c. Technology/equipment	$
d. Materials (consumables)	$ Expenses for consumables used in the course of the program, exhibit or project.
e. Evaluation	$ Expenses related directly to measuring outcomes used in the final report.
f. Miscellaneous (include description below)	$
g. Collection	$
TOTAL	$

In-Kind Narrative - Partner

a. Personnel - estimated time/hourly expense donated by partner and/or contracted services

b. Advertising/Marketing

c. Technology/Equipment

d. Materials (consumables)

e. Evaluation

f. Miscellaneous

g. Collection

Summary

	Grant Request	In-Kind Total	Total
a. Contracted Services/In-Kind Personnel	$	$ Total of In-Kind from Library and all Partners.	$
b. Advertising/Marketing	$	$	$
c. Technology/Equipment	$	$	$
d. Materials	$	$	$
e. Evaluation	$	$	$
f. Miscellaneous	$	$	$
g. Collection	$	$	$
TOTAL	$	$	$

SELCO use only

Budget figures have been checked

Yes

FY 2019 Community Collaboration Grant Application

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