Grant Application Clive Community Foundation PO Box 71367 Clive, Iowa 50325 clivecommunityfoundation.org Please note: Upon submittal, you will receive an email of your completed application. CCF Grant Application - Part I 3 Core Focus Areas: Quality of Life Initiatives – support for public art, parks and trails, and educational programming. Health & Wellness – food assistance, nutrition education and health management resources. Community Collaboration – partnering with civic organizations, neighboring cities and foundations, and other non-profits that share our mission. Project Title:*Date:* Date Format: MM slash DD slash YYYY Legal Name of Organization (as listed with the IRS):*Employer Identification Number (EIN) - if available:Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone:*Website: Indicate which:*IRS 501 (c)IRS 501 (3)IRS 501 (5)IRS 501 (6)IRS 170bName of contact person regarding this application:* First Last Title of contact person regarding this application:*Phone of contact person:*Email of contact person:* Name of fiscal agent contact person (if different from above) First Last Title of fiscal agent contact person (if different than above)Phone of fiscal agent contact person:Email of fiscal agent contact person: Physical address of fiscal agent contact (if your organization is neither a IRS 501 (c)(3)(5) or (6) or 170b, you MUST have a fiscal agent. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Total Cost of Project:*Total requested from CCF:*% of matched Funds:*Clive population served (estimate #):*Type of Request:Capital Based (The building of or physical improvement of something.)Special ProjectOn-going ProgramProject Focus Area (Check as many as apply)* Quality of Life Community Health Community Collaboration In no more than three sentences, describe your organization.*In no more than three sentences, describe the project for which you are requesting funds.*Grant Application - Part IIDescribe the proposed project in detail, including your goals and objectives.*How does this project support CCF's mission?*Specifically how does the project/program advance one or more of CCF's three core focus areas listed above?*Discuss the community need for the project, the benefits for the community as a result of the project and the community support of the project.*Will this project take place within the City of Clive? If not, state the percentage of the program which will take place within city boundaries.*Include the target population and the expected number of people you will serve.*How would or does this project/program include community partners? How would project/program raise the visibility of CCF and the community of Clive?*Outline other resources or partners identified to assist with the project, and other funding applied for or secured for the project.*In the first question you described the project goals and objectives. How will you measure the impact of the project and if the goals and objectives were reached?*What is your timeline for this project?*Project Budget. Please itemize the items needed to complete the project and their costs. Also show the source and amount of the funds used to cover the costs. This should incude the amount of your request from the Clive Community Foundation as well as other funders.*IncomeSponsor Cash:Source:Amount: Federal Gov. Grants:Source:Amount: Polk County Grants or State Grants:Source:Amount: Private Foundations:Source:Amount: Sponsor In-Kind:Source:Amount: Private In-Kind:Source:Amount: Other Income:Source:Amount: CCF Request:Source:Amount: Total Income from above:ExpensesLand Purchase:Source:Amount: Professional Services:Source:Amount: Construction Costs:Source:Amount: Equipment Purchase:Source:Amount: Construction Supplies:Source:Amount: Training Costs:Source:Amount: Personnel Costs:Source:Amount: Other Expenses:Source:Amount: Total Expenses from above:Part III - Approval from Applicant OrganizationWe approve submission of this grant request and certify that the purpose of this request is charitable and that monies received from the Clive Community Foundation will be used solely for the project stated in this application.Applicant Name:Date Submitted:* Date Format: MM slash DD slash YYYY Part IV - AttachmentsAttachments:*Please attach the required documents in pdf format: Copy of IRS Federal Income Tax Exempt Letter, List of Board of Directors, other items such as bids or estimates. Drop files here or Accepted file types: pdf. CAPTCHATo prevent spam, please complete the Math Challenge.