Fill and Sign the Enrollment Forms Are in PDF Format and Require Adobe Reader

U.S. Bancorp Foundation 2010 Grant Application Instructions Please be sure to review the U.S. Bancorp Foundation Grant Guidelines before completing this application. You may reproduce this form on your computer, or type or legibly print the requested information. Please keep your answers as brief as possible. This application is available on the Web at usbank.com. All grant applicants: Please complete all of Section I, include the required attachments, and sign and date the application. If the grant request is $5,000 or more: Also complete all of Section II. I. All Grant Applicants: Complete Section I. Name of Organization: Federal Tax Identification Number: Address: City: State: Telephone: Zip Code: Fax: Organization Web Address: Executive Director (Mr. Mrs. Ms. Other): Telephone: Fax: E-Mail Address: Primary Contact, if other than Executive Director (Mr. Mrs. Ms. Other): Title: E-Mail Address: Telephone: Fax: 1. Amount Requested: $ Date of Application: 2. Type of Request (check one): Operating Capital Program Project Other 3. If the request is not for operating support, briefly describe the program or project for which the organization seeks support. 4. Does the request address one of the U.S. Bancorp funding priority areas? Yes No If yes, select one: Economic Opportunity Education 2010 U.S. Bancorp Foundation Grant Application Cultural & Artistic Enrichment United Way Page 1 5. Has the organization received a grant from U.S. Bancorp Foundation in the last three years? Yes No If yes, please list dates and amounts. Date: $ Date: $ Date: $ 6. Please list any U.S. Bancorp employees involved in your organization and their roles (please do not include banking relationship or account information). 7. Does the organization receive support from United Way? Yes, ______% of budget No 8. Please provide a brief overview of the organization: 9. Of the clients you serve, what percent are in the following categories? For ALL United Way applications, please estimate the total percentage of clients served that meet the guidelines of low- to moderate-income families (below 80% of area median income). ________% Income Do not track Less than 50% of area median income* Between 50% - 80% of area median income* Between 80% - 100% of area median income* More than 100% of area median income* Total % % % % 100% *Area median income information can generally be found at the following web site: www.huduser.org/datasets/il.html Ethnicity Do not track Caucasian African American Hispanic Asian American Native American Multi-racial Other (please specify): Total Gender Do not track Females Males Total % % % % % % % 100% % % 100% STOP: If the request is less than $5,000, skip Section II. Please sign/date the application and include the required attachments. II. If the Grant Request is $5,000 or More: Complete Section II. Financial Information The organization’s current year budgeted expenses of $ % higher lower than the previous year’s actual expenses. are 2010 U.S. Bancorp Foundation Grant Application Page 2 1. During the current fiscal year $ or % of the total expense budget is for administrative/overhead and fundraising expenses. 2. Has the organization experienced an operating deficit (i.e., expenses exceeded revenues) in the last two years? Yes Year Deficit $ Year Deficit $ No If yes, what was the amount of the deficit? Please explain the deficit(s) above and the plan for reducing or eliminating it. Project Information (Complete only for program, project or capital support) 1. What are the timelines for the project and for fundraising? 2. What is the budget for the program/project? $ 3. How does this effort address a community need? Please describe the community and clients that will benefit. 4. Please explain how you have measured or will measure the success of the program/project. III. Required Attachments for All Grant Applicants Please enclose one copy of each of the following items: 1. Cover letter 2. A copy of your current IRS determination letter indicating tax exempt 501(c)(3) status 3. Board of Directors list, including names, phone numbers and affiliations 4. Annual report, if available, or other material summarizing activities of the organization 5. Current year itemized operating revenue and expense budget for the organization 6. Most recent audited financial statements or IRS Form 990 7. A list of major corporate and foundation donors for the past two years If you completed Section II, please also enclose one copy of each of the following items: 8. A one-page summary of the organization’s three major core programs or activities 9. Budget of program, project, or capital campaign Authorization The undersigned certifies that they are authorized to represent the organization applying for a grant and that the information contained in this application is accurate. The undersigned agrees that if a grant is awarded to the organization: (1) the grant will be used for the purpose outlined in the grant award letter and may not be expended for any other purpose without prior written approval from U.S. Bancorp, (2) U.S. Bancorp has received nothing of material value in exchange for the grant, and (3) information about the organization and the grant may be used by U.S. Bancorp in any published materials. Signature of Executive Director or Board Chair 2010 U.S. Bancorp Foundation Grant Application Date Page 3