NextGen Application SECTION ONE – Organization InformationApplicant Organization (Legal Name)*Doing Business AsPrevious Name, if changedAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Website Phone*IRS Name, as listed on 501(c)(3) letter*IRS Letter Date* Month Day Year Tax Exempt ID Number (EIN)*Name of Executive Director* First Last Executive Director Email* Executive Director Phone*Organization’s Budgeted Expenses for Current Year*Endowment Size*Organization’s Major Funding Sources* Organization’s Affiliation and/or Accreditation BodyCheck all that apply United Way Fine Arts Fund Better Business Bureau Chapter of national or regional organization Other None Please specify national or regional organizationPlease specify other affiliation and/or accreditationRequest InformationProgram/Project Title*Total Budget for this Program/Project*Note: The amount of this request is $5,200.Is the Proposal Contact person different than the Executive Director?* Yes No Contact Name* First Last Contact Title*Contact Phone*Contact Email* Community/Counties to be served by this Program/Project*Brief demographic description of population served by this Program/Project*Potential Number to be served by this Program/Project*Type of Grant Request*Check all that apply Capital Expenditures Programming Endowment Research & Development Collaborative Project/Program SECTION TWO – Profile of OrganizationGive a brief summary of organization’s history*Share the organization’s vision/mission*Give a brief description of current programs/projects and activities*Describe organization’s constituency and geographic region of service*SECTION THREE – Proposed Program/Project DescriptionDescribe the proposed program/project, including at least: (1) Goals or objectives of the proposal (2) Community need and how it will also benefit young people in our community (3) Activities to accomplish the program/project (Note: Indicate whether this is a new or an expanded or modified program/project; if expanded or modified, identify how it increases your organization’s outreach.) (4) Timetable for implementation*What is the life expectancy of the proposed program/project?*Explain why your organization is especially qualified and appropriate to address this need or benefit*Describe the impact of this program/project on the community; include at least: (1) An estimate of the numbers of persons who could benefit (2) Outline of the geographic areas served (3) Benefit to the Greater Owensboro area*SECTION Four – Required Financial AttachmentPlease upload the following file (PDF format only)*Submit the Proposed Program/Project Budget for your entire project (see example Form C) clearly indicate which portions will be funded by the Impact100 NextGen Grant. Also specifically indicate how you will fund the balance of the project. Drop files here or Select files Accepted file types: pdf, doc, xlsx, Max. file size: 50 MB, Max. files: 10. SECTION FIVE– Required Non-Financial AttachmentsPlease upload the following non-financial files (PDF format only)*(1) Include a copy of your IRS letter of determination 501(c)(3). (2) Provide an organizational chart. (3) Include an example of any of the following: annual reports, organizational brochures, sample newsletters, and/or program. Drop files here or Select files Accepted file types: pdf, doc, xlsx, Max. file size: 50 MB. Permission to Record and Grant AgreementPermission to Video Record Site Visits*By clicking the box below, I grant Impact100 permission to record the site visit at my organization and to share the recording with all Impact100 NextGen members. Yes, Impact100 NextGen may video record our site visit.Terms of Grant Agreement for Impact 100 Owensboro*(1) Applicant agrees that any grant received from Impact100 NextGen will be expended for the explicit purposes described in the grant proposal. In the event grant monies are to be allocated for any other purpose, agreement must be obtained from Impact100 NextGen. (2) If a grant is received, applicant agrees to credit Impact100 NextGen in the manner identified by Impact100 NextGen in any publications (including annual reports, newsletters) press releases, brochures, videotapes, and other publicity or public relations materials and presentations. (3) Applicant agrees, following expenditure of any grant received, to return a follow-up report to Impact100 NextGen. An itemized budget is part of the report. I have read and understand the Terms of Grant Agreement, and, should a grant be received, agree to follow its terms and conditions.EmailThis field is for validation purposes and should be left unchanged.