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Maine Humanities Council Discretionary / Planning Grant Application Form Revised 2/12 Dear Applicant: Thank you for your interest in a Maine Humanities Council Discretionary Grant. The goal of this program is to provide small matching grants, up to $500.00, for public programs in the humanities or for planning larger programs. Before you complete this application – or submit it – you should have • reviewed all the MHC Grants program material on the MHC web site http://mainehumanities.org/grants/index.html • spoken to a MHC staff member about your project. (Anne Schlitt or Lizz Sinclair at 207773-5051) Remember, your application must be submitted at least 8 weeks before your project begins! Applications are accepted and reviewed on a rolling basis, and they consist of four parts: • The Cover Sheet (attached). Please include your telephone number. • The Budget Form (attached). Please attach a budget narrative to explain other sources of income, contingency plans, and details of salaries, etc. Most MHC questions are about budget items that are unclear. • Certification Form (attached). This must be signed by an authorized representative of your organization. • The Narrative – This is where you tell us what you are planning to do. Please provide enough detail to explain the project and its components, including your plans for publicity. Be sure to provide the dates of any public events. (2 pages max., 12 pt. type, 1” margins) Please submit 4 copies of your completed application by mail to Maine Humanities Council, 674 Brighton Avenue, Portland, ME 04102 If you have any questions, please feel free to contact us – we’re here to help! Sincerely, Anne Schlitt Assistant Director Lizz Sinclair Program Director 1 Maine Humanities Council COVER SHEET: DISCRETIONARY/PLANNING GRANTS 1. Project Title: 2. Sponsor: (name, address, phone, e-mail, principal officer) 3. Co-Sponsor (if applicable): (name, address, phone, e-mail, principal officer) 4. Project Director: (name, address, phone, e-mail) 5. Submission Date: 6. Project Duration: (from, to) 7. Dates, Times, Locations of public programs for which you are seeking funds1: 8. Size of Anticipated Audience: 9. Has your organization received MHC funding in the past? If so, please list the titles and grant award amounts of projects for which you have received funds within the past three years: 10. State (not Federal) Representative: 11. Your project incorporates: (check all that apply) ___History ___Religion ___Literature ___Languages ___Philosophy ___Art History State (not Federal) Senator: ___Cultural Studies ___Classics ___Other (Please specify): __________________ 12. Abstract: Please provide a concise one or two sentence description of your project that we can use in our records, newsletter, and reporting. 13. BUDGET 14. Fiscal Agent (If different from #2 Above): (name, institution, address, phone, e-mail) Requested from MHC: $ Grantee Cost-share Cash: $ In-kind: $ Total Project Cost: $ (MHC + Grantee) Mail to: Maine Humanities Council, 674 Brighton Avenue, Portland, ME 04102-1012 1 If your request is for planning a larger public humanities program, and exact dates are not yet set, please give us an estimate of when your project will occur. 2 Maine Humanities Council BUDGET FORM: DISCRETIONARY & PLANNING GRANTS Please outline the costs of your project. By double-clicking on this chart, you can open it in Excel and fill it out digitally. Use an extra sheet if you have unusual expenses you wish to explain, or if you want to provide us with any additional details. In column A, show the funds you are requesting from us; in columns B&C, show us how you will match the grant using cash and/or in-kind contributions; and in Column D, add A through C for a total project cost. In addition, in your budget narrative, please provide specific details on any salaries and fees that you want this grant to pay for. Who will be paid, and what will they be doing for the project? Please also detail any other income you anticipate generating for the project, either from other funders or through earned sources, and what you will do if those funds don’t materialize. A. MHC Funds B. Your Cash Match C. In-Kind Match D. Total Cost A. Salaries & Fees 1. Administrative 2. Consultant Fees * B. Office/Meeting Space 1. Rental / In-Kind C. Supplies 1. Books 2. Other materials D. Publicity / Communications 1. Postage 2. Telephone 3. Duplication 4. Printing E. Travel 1. Mileage F. Other (List below and explain on another sheet) TOTAL (Must not Exceed $500) * please provide a description of the roles, qualifications and costs of any consultants used in your project. 3 CERTIFICATIONS: TO BE SIGNED BY THE APPLICANT AND SUBMITTED WITH YOUR PROPOSAL Because a portion of Maine Humanities Council grant funds may originate with the Federal government, applicants must certify that they will make all reasonable efforts to comply with the following federal nondiscrimination and ineligibility provisions: 1. Certification Regarding Nondiscrimination (a). Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), which provides that no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the applicant received federal financial assistance; (b). Section 504 of the Rehabilitation Act of 1973. As amended (29 U.S.C. 794), which prohibits discrimination on the basis of handicap in programs and activities receiving federal financial assistance; (c). Title IX of the Education Amendments of 1972, as amended (20 U.S.C. 1681 et seq.), which prohibits discrimination on the basis of sex in education programs and activities receiving federal financial assistance; and (d). the Age Discrimination Act of 1975, as amended (42 U.S.C. 6101 et seq.), which prohibits discrimination on the basis of age in programs and activities receiving federal financial assistance, except that actions which reasonably take age into account as a factor necessary for the normal operation or achievement of any statutory objective of the project or activity shall not violate this statute. 2. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion (a). The applicant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency. (b). Where the applicant is unable to certify to any of the statements in the certification, such prospective participant shall attach an explanation to this proposal. Signature of Authorized Representative: _____________________________________________ Name (print): __________________________________________________________________ Title: _________________________________________________________________________ Date: _________________________________________________________________________________ 4