ATTACHMENT A
Nonprofit Workplan Phase 1 Grant Application
ORGANIZATION INFORMATION
Are you a 501 (c)(3) nonprofit organization? Yes
No
Organization Name Year Funded EIN (Tax ID#)
Contact Person Title
Email Address Phone Number
Mailing Address Website
ABOUT YOUR ORGANIZATION
What is the mission of your organization?
Number of Employees Full-Time Staff____
Part-Time Staff___
Volunteers___
In the last two years, have you been awarded a grant or other direct funding by the City? If so, explain.
Are you qualified to apply for the Human Services Resource Allocation Program (HSRAP), Community Development Block Grant (CDBG), or Emerging Needs grant programs? If so, did you apply? Explain why or why not.
PROGRAM & COMMUNITY IMPACT
Name of Program: Grant Request Amount: $
Please provide a narrative describing your proposed program:
Total Number of people estimated to be served by this
program:
Total number of Palo Alto residents estimated to be served by this program:
Total number of Palo Alto residents estimated to be served by your agency:
Total number of unduplicated Palo Alto residents estimated to be served by the requested funding amount:
EQUITY IMPACT
Does your organization serve historically underrepresented or underserved populations? If yes, please describe. (ex.
Number or percent of demographic populations)
What measures does your organization take to promote services to underserved populations? Social Media Website
Location of program/services Direct mail
Other: (Please describe)
What fees will be charged for proposed services, if any? Will subsidized or fee waivers be offered to clients?
ALIGNMENT WITH CITY COUNCIL PRIORITIES
Briefly describe how your request supports one or more of the City Council Priorities (2-3 sentences). If not relevant indicate with “N/A.”
Climate Action and Adaptation & Natural Environment Protection:
ATTACHMENT A
Economic Development and Retail Vibrancy:
Implementing Housing Strategies for Social & Economic Balance:
Public Safety, Wellness & Belonging:
PROGRAM GOALS
Please use the template below to list up to 3 goals related to the program(s) you are proposing with requested funding.
For each goal identify 1-3 strategies your organization will implement to achieve this goal. For each strategy, provide an objective and an outcome. Attach your Program Goals.
Example:
Goal: A general statement about the desired long-term impact.
Example: "Enhance STEM education access for underrepresented middle school girls in underserved areas.” Strategy: The overall approach or method used to achieve the goal.
Example: "Partner with local schools to develop and deliver hands-on STEM workshops led by female science professionals.”
Objective: Specific, measurable actions that need to be completed to reach the goal. Example: "Train 20 female STEM professionals to facilitate workshops reaching 100 middle school girls per year.” Outcome: The positive change or result that occurs as a direct consequence of the project activities. How will you know that the strategy is successful?
Example: "An increase in the number of girls expressing interest in pursuing STEM careers post-workshop participation.”
Describe your organization’s plan for evaluating the program’s effectiveness? Include any specific measurement tools to be used such as surveys or other tools.
PROGRAM SUSTAINABILITY
What amount and percent % of your organization’s budget is currently funded by the following:
Government Grants$_____, ___%
Private Donations$_____, ___%
Fundraising$_____, ___%
Membership Fees$_____, ___%
Fees for service$_____, ___%
Other$_____, ___%
What percentage of your organization’s annual budget does the grant request represent? •Annual Budget: $____
•Grant Request Amount: $____
•Percent of Budget: (Grant request/Annual Budget) x100 = ___% If awarded, will the contribution be used to leverage other funding opportunities? Explain (1-2 sentences).
Describe specifically how the requested funding will be used.
REQUIRED ATTACHMENTS (Section in development)
•Program Goals •IRS Determination Letter (501 (c)(3) status proof REPORTING REQUIREMENTS – (Section in development)
Requests of up to $5,000- brief annual report (1-2 pages) summarizing key activities and basic financial and community impact highlights. Financia reporting will consist of a self-certification of compliance with grant terms.
Requests >$25,000-
-Annual report on service outcomes
and performance metrics.
-CPA-prepared or reviewed financial
statements, or
-IRS Form 990
Requests $25,000-$100,000-
-Semi-annual reports on service
outcomes and performance metrics.
- CPA-prepared or reviewed financial
statements.
Requests $100,000+
-quarterly service outcomes and
performance metrics, and a year-end
community impact report.
- CPA-prepared or reviewed financial
statements.