Sample Application
Contact Information
Legal Name
This must agree with IRS records.
Neighborhood Food Pantry
Organization Name
Change this to the name under which you are most commonly known as, if different from IRS records.
Neighborhood Food Pantry
Address
P.O.Box 1234
City
Chicago
State
IL
Zip Code
60606
County
Cook County
Phone Number
Do not use dashes xxxxxxxxxx
3121234567
Fax
Do not use dashes xxxxxxxxxx
3127654321
Website
www.neighborhoodfoodpantry.org
Primary Contact Information
Whom should we contact if we need additional information on this particular grant request?
Prefix
Mr.
First Name
John
Last Name
Smith
Title
Director of Development
Daytime Phone Number
Please list the primary contact's direct dial phone number. Do not use dashes xxxxxxxxxx
3121234566
Extension
E-mail
john@neighborhoodfoodpantry.org
Secondary Contact Information
This should be the Executive Director or Board President or another senior agency staff member.
Prefix
Ms.
First Name
Jane
Last Name
Mitchell
Title
Executive Director
Daytime Phone Number
Please list the direct dial phone number. Do not use dashes xxxxxxxxxx
3121234555
Extension
E-mail
jane@neighborhoodfoodpantry.org
Organization Background & Grant Request
Organization Background
Year Founded
1975
Background
Please provide the mission and a brief history of the organization, the community and the individuals you serve, and how the organization has evolved since its funding.
The Neighborhood Food Pantry is a non-profit organization, founded in 1975, with the mission of eliminating hunger in our community by providing food to those in need, inspiring independence for our clients through self-help initiatives and innovative programs, and raising awareness of hunger. Those we serve are of every race, religion, age and background. Last year, Neighborhood Food Pantry merged with the Community Food Pantry. The merger of our two organizations has helped broaden our presence in Chicago and brought a higher level of service to those in need in our community. When Neighborhood Food Pantry began, it was operated by a few volunteers. Thirty-four years later, we have one part-time and three full-time staff people, a crew of 100 volunteers, and we are governed by a volunteer board of directors.
How many people currently serve on your board of directors?
12
Grant Request
Request Title
Please list the project title, not a description of the project. (Examples: Seniors Health Program or 2009 General Operating Support )
Operation: Cool It
Request Date
Please use today's date.
July 28, 2009
Request Amount
$11,500
Geographical Area Served
Use the drop down list to find the closest match to the main area served by your agency. You may choose up to three areas.
Cook County
Programs and Services
Without repeating what you included in the Background field, please describe the program for which you are requesting support. If you are requesting general operating support, describe the major programs and services provided by your organization.
Please include:
• the need(s) you are meeting;
• the issue(s) you are addressing and its relationship to the organization's mission;
• a detailed description of the program for which you are seeking support or the major programs and services provided by your organization if you are seeking general operating support; and
• a description of the population you serve. What are their needs? What obstacles does this population face?
Presently, the Neighborhood Pantry provides food to approximately 300 households composed of about 900 individuals every month, including 550 children under age 18. Families range in size from 1 to 12. Ethnicities represented include African-American, Caucasian, Hispanic andAsian-American. We provide supplementary nutrition to individuals who are in need, due to unemployment, illness/disability, homelessness, or domestic crisis. In order to distribute a wider variety of food, including fruits, vegetables and meat and dairy products, we require funds to purchase freezers and refrigerators for both of our locations, in which to store a variety of healthier food options. Funds are also being requested to supplement the maintenance and utility costs of the appliances.
People served by the Organization
How many people are directly served annually by your organization? Please enter a whole number, not a range. Estimates are fine.
10,800
People served by the Program
If you are seeking program support, how many people are directly served annually by that program? Please enter a whole number, not a range. Estimates are fine. If seeking general support, you may leave this field blank.
8,000
Goals
What are the program goals for this fiscal year? Is there a benchmark (national, city, agency, etc.) by which you set these goals? How will you determine if the program has satisfied these goals? What were the program goals for last fiscal year? Did you meet your goals?
Our goal for this new program, set by our Board, is to offer a wider variety of foods that are healthy. In line with the FDA approved food pyramid, our goal is to ensure that every individual served receives at least three servings of fruit, four servings of vegetables and one serving of meat and dairy each day. In order to achieve this goal, we need adequate refrigerator/freezer space in which to store perishable items we have previously not been able to keep on hand.
Recent Accomplishments
What have been some of your recent accomplishments?
After this year's Volunteer Drive, we welcomed eleven new, regular volunteers. We also challenged our current volunteers to bring a friend, which resulted in six new, regular volunteers. Because of this, we were able to increase our hours of operation to include Sundays and evenings. This helped tremendously in accommodating working clients.
Recent/Anticipated Challenges
What challenges have you experienced or do you foresee in the upcoming year?
The challenge we are experiencing now is rising need. We have been able to keep up with the growing demand thus far, but there is an expressed need for perishable foods, for which we have very limited storage space. In order to meet the intense need, Pantry staff have combined resources and implemented a variety of growth plans. The community has responded with generosity, enabling us to continue to provide consistent emergency food to our increasing number of hungry neighbors.
Salary Information
Please provide the titles and salaries for the agency's five highest-paid employees and the number of years at the current position. If any of these five positions have been filled for less than a year, please list the previous salary and the number of years in the position.
Executive Director $48,000 (full time) 7 years
Director of Development $36,000 (full-time) 9 months (previous employee, $37,000-4 years)
Volunteer Coordinator $33,000 (full-time) 5 years
Community Liaison $19,000 (part-time) 2 years
Administrative Assistant $15,000 (part-time) 4 years
Board Support
Board Giving
What was the total amount personally contributed by members of the board of directors for the most recently completed fiscal year?
Contributions through board member personal trusts, family foundations, or donor advised funds may be included only if the individual board member personally contributed the funds held by the trust, foundation, or donor advised fund.
$8,500
How many of the board members gave a personal cash gift in the most recently completed fiscal year?
12
What was the range of personal giving from the board?
Please list the lowest amount and the highest amount.
$100 - $2500
Board Fundraising
What was the total amount raised by the board members for the most recently completed fiscal year?
Please exclude all personal board member contributions and the value of in-kind goods or services.
$32,000
How many of the board members raised funds in the most recently completed fiscal year?
Please exclude all personal board member contributions and the value of in-kind goods or services.
9
What was the range of amounts raised by board members?
Please show the lowest amount and the highest amount - no names are needed.
$1,000 - $12,000
What is the minimum "give or get" obligation for each board member, if applicable?
If this is not required, please respond "none."
none
Please feel free to share comments on board giving and fundraising.
Our board is very active in fundraising and community relations. All 12 members contribute to our success. All 12 members make a financial contribution to our organization. 6 members provide in-kind services including bookkeeping services, office supplies, and legal help as needed. 5 members work on the gala fundraising committee. All members volunteer at the pantry.
Financial Information
Financial Information - Organization
Total organizational expenses for the most recently completed fiscal year.
$901,000
Total organizational expenses anticipated for the fiscal year for which you are requesting funds.
$990,000
Total organizational surplus (deficit) for the most recently completed fiscal year.
$1,000
Total organizational surplus (deficit) anticipated for the fiscal year for which you are requesting funds.
($24,000)
Deficit
If the organization has recently experienced or is currently anticipating a deficit, please explain what has contributed to the situation and how the deficit will be reduced/eliminated.
We incurred a one-time expense of $25,000 for emergency repairs to our roof. We are petitioning several new donors to off-set this expense.
Total organizational net assets for the most recently completed fiscal year.
$550,000
Total organizational net assets anticipated for the fiscal year for which you are requesting funding.
$515,000
Total organizational revenue from private sources for the most recently completed fiscal year.
This includes individuals, corporations & foundations.
$451,000
Total organizational revenue from private sources anticipated for the fiscal year for which you are requesting funding.
This includes individuals, corporations & foundations.
$476,000
Total organizational revenue from government sources for the most recently completed fiscal year.
This includes local, state and federal contracts and allocations.
$75,000
Total organizational revenue from government sources anticipated for the fiscal year for which you are requesting funds.
This includes local, state and federal contracts and allocations.
$75,000
Total organizational fee-for-service revenue for the most recently completed fiscal year.
This includes insurance reimbursements and third-party payments.
0
Total organizational fee-for-service revenue for the fiscal year for which you are requesting funds.
This includes insurance reimbursements and third-party payments.
$12,000
Major Private Organizational Supporters
Please list your ten largest private organizational supporters during the last 12 months. For multi-year support, indicate the total amount of support and term. (e.g., XYZ Foundation $60,000 - $20,000/yr for 3 years). Also note whether the support is project specific or for general operations. Please exclude in-kind donations.
George Washington Foundation-$75,000/yr for 2 years
John Adams Foundation-$25,000 for 1 year
Thomas Jefferson Foundation-$25,000/yr for 2 years *program support
James Madison Foundation-$15,000 for 1 year
James Monroe Foundation-$10,000/yr for 3 years
John Quincy Adams Foundation- $8,000/yr for 2 years *program support
Andrew Jackson Foundation- $7,500 for 1 year
Martin Van Buren Foundation- $7,500 for 1 year
William Henry Harrison Foundation- $5,000/yr -annual grant
John Tyler Foundation- $5,000 for 1 year
Financial Information - Program
The following questions are specifically for the program for which you are seeking funding. If you are seeking general operating support, this section is not required.
Total program expenses for the most recently completed fiscal year.
0
Total program expenses anticipated for the fiscal year for which you are requesting funds.
$80,000
Total program surplus (deficit) for the most recently completed fiscal year.
0
Total program surplus (deficit) anticipated for the fiscal year for which you are requesting funds.
0
Program Deficit
If the program has recently experienced or is currently anticipating a deficit, please explain what has contributed to the situation and how the deficit will be reduced/eliminated.
Total annual program revenue from private sources for the most recently completed fiscal year.
This includes individuals, corporations & foundations.
0
Total annual program revenue from private sources for the fiscal year for which you are requesting funding.
This includes individuals, corporations & foundations.
$80,000
Total program revenue from government sources for the most recently completed year.
This includes local, state and federal contracts and allocations.
0
Total program revenue from government sources for the fiscal year for which you are requesting funds.
This includes local, state and federal contracts and allocations.
0
Total program fee-for-service revenue for the most recently completed year.
This includes insurance reimbursements and third-party payments.
0
Total program fee-for-service revenue or the fiscal year for which you are requesting funds.
This includes insurance reimbursements and third-party payments.
0
Major Private Program Supporters
Please list your ten largest private program supporters during the last 12 months. For multi-year support, indicate the total amount of support and term. (e.g., XYZ Foundation $60,000 - $20,000/yr for 3 years). Please exclude in-kind donations.
Thomas Jefferson Foundation-$25,000/yr for 2 years
John Quincy Adams Foundation- $8,000/yr for 2 years
Triangle Foundation $8,000 for 1 year
Square Foundation $5,500 for 1 year
Mr. & Mrs. Carl Diamond $3,000 for 1 year
Big City Food Bank $2,500 for 1 year
Little Town Corporation $2,500 for 1 year
The Lodge $2,000 for 1 year
Mr. & Mrs. Michael Gomez $1,000 for 1 year
Mr. & Mrs. Tom Donner $1,000 for 1 year
Documents to attach:
- Board of Directors List
Please show any other corporate and/or organizational affiliations and terms of service. If you also have an advisory board, junior board, etc. please include that list as well.
- Financial Statements
Please provide your financial statements for the most recently completed fiscal year. If the audit of those statements is not complete, please provide both the unaudited financial statements for the most recently completed fiscal year and the most recently audited financial statements. If your audited financial statements are not available electronically, please mail or fax a copy.
- Organization Budget
Please provide the current fiscal year budget for your entire organization. Please include both budgeted amounts as well as year to date actual revenue and expenditures. We have a template here that you can use, or you can use your own format as long as all of our required information is included.
- Program Budget
If you are seeking funding for a particular program, please provide the current fiscal year budget for that program. Please include both budgeted amounts as well as year to date actual revenue and expenditures. Again, we have a template here that you can use, or you can use your own format as long as all of our required information is included. This not required if you are seeking general operating support.
- Other Documents
If you have other supporting documents that you would like us to consider, you may attach them with the drop-down title "Other" on the next page.
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