Grantwriting Worksheet

Organization and Tax-Exempt Status

Organization Name *

Also Known As/Doing Business As (D/B/A):

Tax Exempt Status

Federal Tax Identification Number (EIN)

Tax Exempt Date

Date

Time

Will this Organization use a Fiscal Agent or Sponsor

Organization Contact Information

Organization Address

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different than above)

Address Line 1

Address Line 2

City

State

Zip Code

Organization Phone

Organization Email

Website

Primary Contact Name *

First

Last

Primary Contact Title *

Primary Contact Person Phone

Primary Contact Email

Email

Confirm Email

ABOUT YOUR PROGRAM/PROJECT

Request Summary

Project Title *

Requested Amount *

SPECIFICALLY, what will you use the funds for: *

Type of Support (check all that apply) *

Demographics

Geographical Area Served (List specific cities, counties, or states) *

Population Served (i.e. veterans, homeless, at-risk youth, seniors, prisoner re-entry, those who are suicidal or depressed, etc.)

Age Group Served

Gender Served

Request Details

Describe The Program To Be Funded. (Do not describe "why" it's needed. Instead, describe "what" you do each day)

Program Status

New Program: When will this program begin?

Existing Program: When did this program start?

How many people do you anticipate serving/helping in the next 12 months?

How many people did you serve/help in the last 12 months?

What Are Your Program Goals? (i.e. At the end of the program, what do you hope to accomplish?)

List Three (3) Actions Your Organization Will Take to Achieve Your Goals?

Who Do You Partner With? (State the Organization Name, City, and How you Collaborate)

Program Budget

Project Budget Total

List Your Major Sources of Income (i.e. where will you get money from to run this program)?

List Your Major Expenses (i.e. what will you spend money on to run this program)?

ABOUT YOUR ORGANIZATION

Organization Mission:

Organization History/Background:

Organization Board: (List each Board Member and their title).

Organization Staff: Do you have anyone on payroll, if so, please list name, title, and annual salary

LAST YEAR: Income and Expenses (Organization)

INCOME: How much did you receive in Grants and Contributions?

INCOME: How much did you receive for service fees? (i.e. rent, daily care, etc.)

INCOME: What other income did you receive last year? (i.e. board, fundraising)

INCOME: What was your TOTAL INCOME last year?

EXPENSES: How much did you spend on program services?

EXPENSES: How much did you spend on administration (business fees, consultants, accountants, insurance, marketing, postage, etc.)

EXPENSES: How much did you spend on fundraising?

EXPENSES: What did you spend on "other" expenses?

EXPENSES: What were your TOTAL EXPENSES last year?

THIS YEAR: Income and Expenses (Organization)

INCOME: How much have you received in Grants and Contributions?

INCOME: How much have you receive for service fees? (i.e. rent, daily care, etc.)

INCOME: What "other" revenue have you received? (i.e. board, fundraising)

INCOME: What is your total income as of today?

EXPENSES: How much have you spent on program services?

EXPENSES: How much have you spent on administration (business fees, consultants, accountants, insurance, marketing, postage, etc.)

EXPENSES: How much have you spent on fundraising?

EXPENSES: What have you spent on "other" expenses?

EXPENSES: What is the total organization expenses as of today?