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Tutorial: Grant Application For Requests in Excess of $25,000

Sisters of Mercy of North Carolina Foundation, Inc.
Grant Application For Requests in Excess of $25,000

Use this sample Grant Application for Requests in Excess of $25,000. Hover your mouse over the links for helpful tips.


Please complete the application in its entirety and supply the information exactly as requested.

  • The application must be typed or printed with a computer printer in the exact format. It may not be amended or altered in any way. A handwritten copy will not be accepted.
  • Place all required information that does not fit on an application page (audits, budgets, Form 990, responses to questions, etc.) behind the application and reference them to the application section and question (for example, IV.1.). Do not place the information between the pages of the application.
  • All responses to individual questions are limited to a maximum of 250 words unless otherwise indicated. However, you may furnish supplementary data (e.g., news article or brochure) describing your project or program.
  • The last page of the application must be signed by the organization's chief executive officer and the chairperson of the board of directors. Mechanical, copied and stamped signatures are not acceptable.
  • Submit only the original grant application form and one copy of any supplementary data. Reproduced copies of the application form will not be accepted. All pages must be single-sided. Faxes are not acceptable.

    NOTE: If your organization is in the Western North Carolina region, please submit a copy of your application package, along with the original, to the Foundation’s Asheville office.
  • If you have any questions about the application, please call the Foundation’s office in Charlotte at (704) 366-0087. If your organization is in the Western North Carolina region, contact the Foundation’s Asheville office at (828) 281-8184.

1. Date of Application: ______________________________________________

2. Name of Organization: ____________________________________________

3. Address: _______________________________________________________

4. Telephone: _____________________________________________________

5. Facsimile: ______________________________________________________

6. E-mail: ________________________________________________________

7. Chief Executive Officer: __________________________________________

8. Contact Person: _________________________________________________

9. Taxpayer Identification Number: ___________________________________

10. Please attach a copy of your organization's IRS 501(c)(3) Letter of Determination.

The letter should indicate the organization's specific classification and that it is not classified as a private foundation within the meaning of Section 509 of the IRS Code.

11. Does the organization file an IRS Form 990? Yes__No__

If yes, please attach a copy of a current Form 990. If no, please attach a statement of explanation. (The Form 990 must be completed no later than six months following the close of the organization’s most recent fiscal year to be considered current and meet the submission requirements.)

12. Type of organization: Corporation__ Trust __ Other__

If other, please attach a statement of explanation.

13. Attach a list of the organization's officers indicating title and city and state of residence.

14. Attach a list of the members of the Governing Board indicating city and state of residence.

15. Does the organization control or is it controlled by any other corporation?


If yes, please attach a statement of explanation.

16. Has any federal, state or local governmental agency or body ever asserted that the organization has engaged in any illegal conduct?


If yes, please attach a statement of explanation.

17. Please attach a history of the organization.

18. Attach a statement describing your organization’s mission, goals and major program(s). Indicate the number of people served by your agency/program(s) in the previous year.


1. Please identify your organization's fiscal year end: ____________.

2. Please attach a copy of the most recent Audit or Compilation Report of the organization's financial statements by a public accounting firm. The Audit or Compilation Report must be completed no later than six months following the close of the organization’s most recent fiscal year to be considered current and meet the submission requirements.

As a rule, an Audit will be expected if an organization’s annual revenues and support exceed $500,000. Below that threshold, a Compilation Report is acceptable.

Note that organizations awarded a multi-year grant will be required to provide the Foundation with a copy of a current Audit or Compilation Report, whichever pertains, during the grant term as part of the annual evaluation process.

3. Attach a copy of the organization's current fiscal year capital and operating budgets.

4. Attach a copy of the organization's statement of year-to-date income and expenses.

5. Please indicate your organization's primary funding sources and the amount(s) of such funding in terms of dollars and as a percentage of the total. (The amounts and percentages must tie either to your annual budget or to amounts stated in the Audit or Compilation Report.)







6. Has your organization received previous Sisters of Mercy of North Carolina Foundation grants?

Yes__ No__






7. If the grant request is for operating funds, check the box__ and indicate how grant funds would be spent on the budget form on page 7. Then proceed to Section IV.


If the request is for a specific project, check the box__ then:

• Indicate the total cost of the project for which grant funds are being requested.

• Attach a copy of the total project budget

• Indicate how grant funds would be spent on the budget form on page 7 (or question 8 section 3)

• Identify the sources and amounts to be raised for the project in the space provided   below. (Note: The amounts requested should equal the total cost of the project.)










8. Budget Form

On the form below, identify which line items would be funded by this grant request. (Use this form to only indicate how grant funds would be spent)

Note: The Foundation typically does not fund items such as administrative overhead, advertising, community education, seminars, food and refreshments, incentives, handbook or manual publication, staff training, "scholarships" or direct payments to or for individuals.

Expense Items SOM grant request
Year 1 Year 2 Year 3




$ $ $


$ $ $

Contract Services:

$ $ $


$ $ $
  $ $ $


$ $



Other Operating:


Occupancy (rent, mortgage, utilities):

$ $ $

Office Expenses (supplies, postage, duplicating, etc.):

$ $ $


$ $ $

Purchased Services:

$ $ $

Service Related Supplies:

$ $ $


$ $ $
  $ $ $
  $ $ $
  $ $ $


$ $



Building Renovation and/or Equipment Purchase: (Itemize expenses according to major categories)

  $ $ $
  $ $ $
  $ $ $
  $ $ $
  $ $ $
  $ $ $


$ $



$ $




Attach a statement responding to questions one through five limiting your response to a total of 1,250 words.

  1. Use of Funds. State specifically how grant funds will be spent. These items should be identified in the project or organizational budget.
  2. Statement of Need. Describe the need for the project or program. Document the need with statistics, credible outside sources of information and/or other quantifiable evidence related to your service area. If this request is for organizational operating expenses, include an explanation of the need for this support.

  3. Project/Program Description. Provide a comprehensive description of the project or program that carefully describes:

    • The structure of the program, the activities/services that will be delivered, how they will address the needs identified, and positively impact those served.

    The number of people to be served and their relevant demographic characteristics.

    If the population to be served is involved in the program design and delivery, what is their role?

    How collaborative relationships are specifically involved and how they impact the success of the program, if applicable.

    Ecumenical and/or multicultural activities.

    Time frames for implementation.

  4. Systemic Change. Does the program or project contribute to systemic change?

    • If yes, name the "system," such as education, healthcare, social service, etc. and;

    • Indicate what barriers (specific problematic policies, procedures, commonly held beliefs or common practices) that are being altered or removed within this system.

    • How will accessibility and/or opportunity improve or increase within this system as a result of program or project efforts?

  5. Sustainment. Describe plans to sustain the organization or program.

  6. Complete the Evaluation Plan on the following page. The Evaluation Plan is expected to be a working document. Should your grant request be awarded, the Foundation will ask you to report on each aspect of the Evaluation Plan in the form of an Interim or Final Report. The Evaluation Plan should not exceed one page.

IV. Evaluation Plan
Please complete questions 1 - 5 in the space provided.

1. Describe your purpose or goals for this grant request. What benefit do you intend to accomplish for the target population?




2. How many unduplicated individuals do you expect to serve annually during the grant term?

Number   Provide Description of Target Population (Examples: homeless women; uninsured adult men and women; abused children, etc.)

3. What are the primary activities/services that will be provided including frequency and numbers served? List as many as three. (If the request is for equipment or renovation, describe activities such as the timeframe for equipment purchase or renovation project completion.)

b. _________________________________________________________________
c. _________________________________________________________________

4. How will clients benefit specifically? What will change? Pick from the categories (knowledge, skill, behavior, condition, other) of improvement(s) or achievement(s) that you consider to be a successful annual outcome for the population to be served. Describe the outcome and indicate what percentage of those served are expected to achieve each outcome. List as many as three in the same order as the corresponding activities above.

  Percent   Category   Outcome Description. (Examples: obtain safe housing; increase savings)

5. What specific measurement tools, data sources and/or methods will you use to measure and verify the outcomes of the program? At what interval will measurements be taken? List each measurement tool in the same order as its corresponding outcome above. (These may include data collection or tracking, surveys, incident reports, interviews, pre- and post-testing.)

b. _________________________________________________________________
c. _________________________________________________________________

6. Amount of Grant Requested: ___________________________
NOTE: The request may not exceed that which was approved at the Grant Application Summary stage.

Payment period requested: Lump Sum _ Installment _
If installment, please indicate requested timing of payment.

Year 1: $_____________ Year 2: $_____________ Year 3: $_____________


We declare that we are authorized to sign this application on behalf of the above organization, and that to the best of our knowledge and belief the information contained in this application is correct. We agree that we will promptly notify Sisters of Mercy of North Carolina Foundation, Inc. of any material changes in this application or the requested supporting documentation during the application process and during the grant term if a grant is awarded to our organization. We also certify that the applicant organization does not discriminate on the basis of race, religion, age, sex or national origin.

Chairperson of the Board _________
Chief Executive Officer _________

The application must be in the name of the organization that holds the 501(c)(3) classification by the IRS.


ABC Family Resource Center would like funding for operating expenses. It operates very much like an independent organization. It has its own director, advisory board, and does its own fundraising. However, the ABC Family Resource Center does not have its own 501(c)(3) classification. It operates under the umbrella of ACME Nonprofit and is included in ACME’s financial audit. In this case, the Applicant will be ACME Nonprofit.

All organizations have a taxpayer identification number, including units of government.

Units of government are exempt from this requirement.

Units of government and some religious organizations are not required to file an IRS Form 990. Additionally, charitable organizations whose annual gross receipts are less than $25,000 are also exempt. If you are unsure of your filing requirement, consult with your accountant or attorney.

If you are applying for the 12/1/11 cycle, and your fiscal year ends:

If you are applying for the 4/1/12 cycle, and your fiscal year ends:

If you are applying for the 8/1/12 cycle, and your fiscal year ends:

Units of state or county government need not submit a financial audit.

Financial statements that are compiled or audited by a board member are not acceptable.

An audit is a process used by an independent certified public accountant (CPA) to test the accuracy and completeness of an organization's financial statements.

A compilation report is also prepared by a CPA using financial data supplied by the organization. It is less detailed than an audit in that the accountant does not review the numbers for accuracy, or express an opinion regarding the information. A compilation report is a less costly alternative for organizations with annual revenue and support under $500,000.

This amount may not exceed the amount approved at the the Grant Application Summary stage.

The payment period must be consistent with the approved Grant Application Summary. If you have been approved to request a multi-year grant, indicate the amount you are requesting for each year.

Operating funds are those expenses necessary for carrying out the generalized purpose or mission of the organization, usually salaries, office expenses, rent, supplies, etc. Organizational start-up funds fall into the "operating funds" category.

Specific project funds are those applied to a specific program, project, equipment purchase, renovation activity, etc. Include a budget for these expenditures.

Describe the need or problem that your program or project is attempting to remedy. It is important that your statement of need be specific to the demographics of your service area. Use local statistics and cite the sources that offer evidence of the problem. National and state statistics are not helpful, unless you are using them to make local comparisons.

Example: A grant request for a program targeting an unemployed population in Swain County might use current unemployment rates to show evidence of need in this area:

Relevant Statistic: At 12.5%, the unemployment rate in Swain County is nearly 3.5 times higher than the North Carolina state average of 3.6%. (North Carolina Economic Profile 2000, Federal Reserve Bank)

Non-Relevant Statistic: The unemployment rate in North Carolina is currently at 3.6%.

These should include the approximate percentage of economically disadvantaged individuals/families to be served. Other useful information includes race/ethnic proportions, age group, gender, and geographic location of the target population.

Organizations and programs that are effective at empowering the populations they serve involve their clientele in the design and delivery of the services provided. If applicable, describe how your program or project employs this philosophy.Some examples of this practice include:

Collaborative relationships are characterized by two or more organizations formally combining resources to address a community need through a shared vision. The end result should be greater than each could have achieved working alone on the problem.

Collaborative relationships are not:

If applicable, attach documentation that outlines the nature of the collaboration including signatures by the participating organizations.

Systemic change occurs when a policy, procedure, commonly held belief or common practice within a community, which has historically created a barrier to certain quality of life benefits, is changed or removed resulting in increased accessibility and opportunity.

Describe how your program or project utilizes religious and ethnic diversity to accomplish its objectives, if applicable.

If this request is for start-up funds for a new organization, program or project, include key dates for initiation of significant phases.

If this request is for building renovation and/or purchase of equipment, include timeframes for phases of construction and completion and purchase.

If the request is for expansion of a project or program, include anticipated hiring dates for new staff and phases of expansion.

If the request is for ongoing general operating support, state the timeframe during which grant funds would be spent.

Describe the strategies your organization, project or program will employ to attract and maintain a broad base of financial support. These strategies should offer evidence that the programs will continue to operate once grant funds have been expended.

When completing this document, you will notice that it does not expand. We are looking for very concise, short answers to the questions below. When you print out this document, please ensure that your responses do not exceed the space provided.

Please give us a general statement that describes how this grant request will directly benefit the people that you serve.

Example: Client A is served 5 times this year and Client B is served 4 times. The unduplicated number of individuals is two, even though these 2 clients were served a total of nine times.

The grant term may be one, two, or three years depending upon what you were approved to apply for. We are looking for the minimum number of individuals you intend to serve on an annual basis.

Include here any eligibility factors that may influence who you will serve. For example: "families who reside in Ashe County and whose income is within 200% of the federal poverty level" or, "children ages 5 - 12 who attend Mountain Elementary and qualify for free/reduced lunch."

Although there may be several services/activities offered by the program, we are interested in those that you consider to be most important in helping your clients reach their goals. You may list one, two, or three activities. Describe the types of services that clients will receive, the number of clients expected to participate, and the frequency or duration of their participation.

Requests for equipment purchases or renovation projects should include a timeline for the primary steps including dates for securing the equipment or completing the renovation project.

Based on previous year's data, or outcome data from a similar program if your project is new, estimate the percent of clients served that will accomplish or achieve the outcome.

Outcomes measure observable improvement. When a client has participated in the services/activities described in question three, there should be a measurable benefit for the participant. These benefits usually fall into at least one of four categories. Choose the category and describe the change:

Improvement in knowledge: When choosing this category, describe the specific information or understanding that people will have as a result of the corresponding activity.

Note: If you choose an outcome in the Knowledge category, be prepared to offer an additional outcome in another category that further demonstrates how clients benefit from increased knowledge.

Improvement in skills: If the outcome category is skill improvement, generally, the client is able to demonstrate a new or improved ability to perform a concrete task.

Improvement in behavior: If your program seeks to change participant behavior, describe the behavior and how it will change.

Improvement in condition: This category refers to a client's general circumstances or state of being.

Other: If the outcomes you are proposing do not seem to fit into any of these categories, choose "Other" and describe the outcome.

Improvement in knowledge examples:

Improvement in skills examples:

Improvement in behavior examples:

Improvement in condition examples:

We are interested in how you will know that the program outcome(s) have been achieved. What method will you use to determine the proposed outcome percentages above? For example, if you are using a standardized test, name the test and frequency of delivery. If you are using data collection or tracking, describe the data and its source. For surveys, describe how and when they will be implemented.


Some organizations are controlled by a national or other affiliate or are considered a subsidiary. If this applies to your organization, please describe the relationship.

The history should include such information as:

If you are engaged in a capital campaign, separate your capital budget from your organization's annual operating budget. Capital campaigns are time-limited in nature and should be kept separate so that an accurate picture of the organization's annualized income and expenses can be determined.

Provide year-to-date actual income and expenses from the beginning of the current fiscal year through at least the most recent quarter-end.