Each request must provide the following information and attachments. Be sure to follow the instructions on word limits and definitions.
- Legal Name and Address
- Tax ID and Status with IRS
- Mission Statement
- Annual Budget Amount
- Number of patients served by organization in the last year (leave blank if your organization does not provide patient services; do not include “clients” if your organization provides services other than medical/dental)
- List of Board of Directors and Major Contributors
- Brief (500 word max) description of the Purpose, Scope, and History of the Organization
- Project Title
- Project Summary (500 word max)
- Questions (300 word max for each)
- Why is this project necessary?
- What are the top three (3) outcomes that will result from implementing this project? An outcome is the desired end state that will be achieved by doing the proposed work. It is not a list of activities. For example, if seeking funding to expand a service line, do not list “hire an additional doctor” as the outcome, but instead use “care for more patients than last year” or whatever the health care achievement will be if the grant is awarded. We recommend using a logic model to outline the needed activities and funding to achieve a particular outcome.
- What metrics will be used to evaluate success or progress towards the above outcomes? Please not only identify the key performance indicators you plan to monitor (example: Number of patients receiving care), but also provide a goal value to each that would denote success (example: Number of patients receiving care increases by 20% in one year).
- How many patients will be directly affected by this project? Over what length of time? If your project does not have a direct service component, please explain in general terms the types of patients that could be impacted by the project.
- Does this project differ from what your organization has done in the past? If so, how?
- Are there other organizations within your service area doing similar work? If so, please specify and explain if/how this project differs from others.
- Project Budget Amount
- Request Amount
- Amount Raised to Date
- List of other Grants or Proceeds Received for Project
- Cover Letter
- Project Description (No more than 2 pages, single-spaced, 12-point font. Please explain the goals of the project and how the proposed work will achieve them. We recommend using a logic model to show how the activities, funding, etc will result in the desired outcomes.)
- Detailed Project Budget
- Organization Budget (current year)
- 990 Form (most recent)
- Audited Financial Statements (most recent)
- Letter of Determination from IRS
- UDS (required for FQHC Clinics only)
- Renderings or drawings, description of the property, and cost estimates (required for building construction or purchase of real property only)
- Annual Report
- Brochure or Fact Sheet