Fill and Sign the Scholarship Application Senator Douglas Jj Peters Form

FOR INTERNAL USE ONLY GRANT # DATE/TIME RECEIVED AMT AWARDED $ JAC Grant Application FY 2012 July 1, 2011 – June 30, 2012 “JAC Grants” is a program funded by the City of Jackson and Madison County and administered by the Jackson Arts Council. GRANT SECTIONS A. APPLICANT ORGANIZATION INFORMATION A. Applicant Organization Information 1. Organization Information B. Grant Information C. Proposal Contact Person D. Arts Advocacy Organization Name: ____________________________________ Mailing Address:_______________________________________ City:_________________________________________________ State: ______ 9-Digit Zip Code: _________________________ Physical Address: _____________________________________ City: ________________________________________________ State: _______ 9-Digit Zip Code: _________________________ E. Narrative F. Project Budget G. Budget for Organization H. Last Year’s Budget I. Assurances Federal EIN:___________________ Email Address: ________________________________________ Website: _____________________________________________ Phone:____________________ Fax: ____________________ 2. Organization Personnel Number of Full-Time: _______ Number of Part-time: ________ Number on Board: ________ Length of Term (years): ________ J. Required Attachment Checklist Grant Deadline: April 19, 2011 Number of Meetings per Year: ________ What is your Board rotation policy? ________________________ ____________________________________________________ Percentage of your Board who are: _____ People of color _____ People with disabilities (Rev. 3/3/2011) FY2012 JAC Grant Application _____ Senior citizens 1 3. Political District in which your organization is located based on your physical address. Only organizations located in Madison County may apply. (For district numbers contact the County Election Commission or visit www.cityofjackson.net/mayor/council/councilmaps/City%20Council%20Map.pdf or http://www.co.madison.tn.us/DocumentView.aspx?DID=205.) Madison County District #: __________ City of Jackson District #: __________ Commissioners’ Names: ___________________ Council Member: _____________________ __________________ ___________________ 4. Date of incorporation as recognized by the IRS determination letter: __________________ 5. Dates of organization’s current fiscal year: Start ______________ End ______________ 6. Provide a brief organizational mission statement. B. GRANT INFORMATION 1. Declare a project title: _____________________________________________________ 2. Grant description (250 characters or less): 3. Date of Activity Beginning: __________________ Ending: ____________________ No earlier than July 15, 2011 No later than June 1, 2012 4. Number of artists participating (do not include children): ___________________________ 5. Number of individuals benefiting from the project: ________________________________ 6. Grant amount requested in this application: ___________________ (Rev. 3/3/2011) FY2012 JAC Grant Application 2 C. PROPOSAL CONTACT PERSON 1. Name: ______________________________________Title:________________________ 2. Mailing Address: _________________________________________________________ City:______________________________ State: ____ 9-Digit Zip Code: ___________ 4. Physical Address: _________________________________________________________ City:_______________________________ State: ____ 9-Digit Zip Code: ___________ 5. Email Address:____________________________________________________________ 6. Home Phone:_____________________ Business Phone: _______________________ D. ARTS ADVOCACY The Jackson Arts Council has devoted considerable time and resources to obtain funding from local county and city government so that this grant program may be offered. It is important that our local elected officials know that the funds supplied to the Jackson Arts Council are used wisely by you, the grantees. Advocacy will help insure future funding for the grant program! Please check the following activities you plan to participate in (if funded, verification of these activities will be requested when you submit your evaluation after your funded project has been completed): All Madison County Commissioners will be invited to attend the funded event (if applicable) All Jackson City Council Members will be invited to attend the funded event (if applicable) If funded, a description of the project and a letter of appreciation for funding the Jackson Arts Council will be sent to all members of the Madison County Commission If funded, a description of the project and a letter of appreciation for funding the Jackson Arts Council will be sent to all members of the Jackson City Council Board members will contact their Madison County Commission representatives to express appreciation for the funding Board members will contact their Jackson City Council representatives to express appreciation for the funding Organization representatives will attend the Jackson City Council meeting when the Jackson Arts Council gives their report in May 2012 Organization representatives will attend the Madison County Commission meeting when the Jackson Arts Council gives their report in April 2012 (Rev. 3/3/2011) FY2012 JAC Grant Application 3 E. NARRATIVE 1. Provide a concise description of the proposed activity in the space below. Explain specifically what grant funds will accomplish. (Rev. 3/3/2011) FY2012 JAC Grant Application 4 2. Who will be responsible for the implementation of the project? If applicable, describe the criteria and the process for selecting artists involved in the project. List all confirmed or proposed artists with a brief bio of each. 3. What methods will be used to publicize your project (e.g., print ads, TV, radio, brochures, website, etc.)? Provide information about the marketing plan. 4. Explain how you will evaluate the success of the project or programs for which you are requesting funds. (Rev. 3/3/2011) FY2012 JAC Grant Application 5 F. BUDGET FOR PROJECT (for which you are requesting funds) TOTAL EXPENSES FOR THIS PROJECT Applicant Cash Match 1. Personnel a. Administrative (itemize) JAC Funds Total i. _________________________ $________ + $________ = $________ ii. _________________________ $________ + $________ = $________ iii. _________________________ $________ + $________ = $________ i. _________________________ $________ + $________ = $________ ii. _________________________ $________ + $________ = $________ iii. _________________________ $________ + $________ = $________ i. _________________________ $________ + $________ = $________ ii. _________________________ $________ + $________ = $________ iii. _________________________ $________ + $________ = $________ d. Other Personnel ______________ $________ + $________ = $________ 2. Space Rental: $________ + $________ = $________ 3. Travel: $________ + $________ = $________ 4. Marketing: $________ + $________ = $________ 5. Other Operating Expenses: Equipment Rental: Shipping: Supplies & Materials: Exhibition Rental Fees: Other Production Costs: Other: ________________________ $________ $________ $________ $________ $________ $________ + + + + + + $________ $________ $________ $________ $________ $________ 6. Capital Expenditures/ Acquisitions: $________ + * 7. Total Cash Expenses: $________ + $________ b. Artistic (itemize) c. Technical (itemize) = = = = = = $________ $________ $________ $________ $________ $________ = $________ = $________ 8. Itemized In-Kind Contributions: _________________________ $________ __________________________ $________ _________________________ __________________________ $________ $________ Total In-kind: $________ * JAC does not fund capital expenses, but costs can be used as Applicant Cash Match. (Rev. 3/3/2011) FY2012 JAC Grant Application 6 F. BUDGET FOR PROJECT (cont.) TOTAL INCOME FOR THIS PROJECT 1. Earned Income: a. Admission Charges, Subscriptions, Box Office Receipts $________ b. Concessions, Sales, Parking, Publications, Rentals, etc. $________ c. Tuition, Class & Workshop Fees $________ d. Sponsor Fees for Performances, Exhibitions $________ e. Sponsor Fees for Optional Services $________ f. Other Earned Income $________ Total Earned Income: $________ 2. Unearned Income: a. Fundraising i. Individual Contributors, Sponsors $________ ii. Memberships $________ iii. Benefits (net) $________ b. Interest on Investments, Endowments $________ c. Other Unearned Income $________ Total Unearned Income $________ 3. Grants: a. Local Government (Do not include this JAC Grant request) $________ b. State Government $________ c. Federal $________ d. Corporate $________ e. Foundation $________ f. Other Grants $________ Total Grants $________ 4. Total Prior-year Carry-over Funds $________ 5. Applicant’s Total Cash Income (sum lines 1, 2, 3, 4) $________ 6. JAC Request for this Proposal $________ 7. TOTAL PROJECT INCOME (sum lines 5, 6)* $________ *Total Application Revenue must be at least as much as Total Cash Expenses. (Rev. 3/3/2011) FY2012 JAC Grant Application 7 G. FY12 BUDGET FOR THE ORGANIZATION (PROJECTED – NOT ACTUAL) BUDGETED EXPENSES FOR FY2012 1. Personnel a. Administrative (itemize) i. _________________________ $________ ii. _________________________ $________ b. Artistic (itemize) i. _________________________ $________ ii. _________________________ $________ c. Technical (itemize) i. _________________________ $________ ii. _________________________ $________ d. Other Personnel _____________________________ $________ Total Personnel $________ 2. Fringe Benefits $________ 3. Professional Services Fees a. Administrative $________ b. Artistic $________ c. Technical & Other $________ Total Professional Services Fees $________ 4. Space Rental $________ 5. Travel & Transportation $________ 6. Other Operating Expenses a. Equipment Rental $________ b. Shipping $________ c. Supplies & Materials $________ d. Exhibition Rental Fees $________ e. Other Production Costs $________ f. Other ______________________________ $________ Total Other Operating Expenses $________ 7. Debt Reduction $________ 8. Capital Expenditures/Acquisition $________ 9. Total $________ (Rev. 3/3/2011) FY2012 JAC Grant Application 8 G. FY12 BUDGET FOR THE ORGANIZATION (cont.) BUDGETED INCOME FOR FY2012 1. Earned Income: a. Admission Charges, Subscriptions, Box Office Receipts $________ b. Concessions, Sales, Parking, Publications, Rentals, etc. $________ c. Tuition, Class & Workshop Fees $________ d. Sponsor Fees for Performances, Exhibitions $________ e. Sponsor Fees for Optional Services $________ f. Other Earned Income $________ Total Earned Income: $________ 2. Unearned Income: a. Fundraising i. Individual Contributors, Sponsors $________ ii. Memberships $________ iii. Benefits (show net gain or loss for previous years) $________ b. Interest on Investments, Endowments $________ c. Other Unearned Income $________ Total Unearned Income $________ 3. Grants: a. Local Government (Do not include this JAC request) $________ b. State Government $________ c. Federal $________ d. Corporate $________ e. Foundation $________ f. Other Grants $________ Total Grants $________ 4. Total Prior-year Carry-over Funds $________ 5. Applicant’s Total Cash Revenues (sum lines 1, 2, 3, 4) $________ 6. JAC Request for this Proposal $________ 7. TOTAL REVENUE (sum lines 5, 6) $________ (Rev. 3/3/2011) FY2012 JAC Grant Application 9 H. PREVIOUS YEARS’ BUDGET FOR THE ORGANIZATION FY11 expenses (budgeted) $________ FY11 income (budgeted) $________ FY10 expenses (actual) $________ FY10 income (actual) $________ If audited, include a copy of the audit report. I. ASSURANCES The Applicant Assures the Jackson Arts Council that: 1. The activities and services for which assistance is sought will be administered by or under the supervision of the applicant. 2. The filing of this application has been duly authorized by the applicant. 3. The applicant will expend funds received as a result of this application solely for the described project or program. By signing this application, the Applicant hereby assures and certifies that it will comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), the Americans with Disabilities Act of 1990 (42 U.S.C. 12101-12213). Application will not be accepted without TWO (2) original signatures in blue ink. Signatures cannot be from the same person. Chief Authorizing Official (Chair or President of the Board) Signature: ________________________________________________________ Title: ________________________________________________________ Name: ________________________________________________________ Date: _____________________ Project Director Signature: ________________________________________________________ Title: ________________________________________________________ Name: ________________________________________________________ Date: _____________________ (Rev. 3/3/2011) FY2012 JAC Grant Application 10 J. REQUIRED-ATTACHMENT CHECKLIST Check all items that apply and are included with this application. This application form with original signatures in blue ink plus seven (7) copies. AFTER making the seven copies, mark on the top of this application form “ORIGINAL.” Attached to this application form and each of the seven copies: One-paragraph bio of key staff. List of Board of Directors with officers and addresses. Describe on the attachment the board selection criteria your organization uses to address inclusive planning, noting which members represent underserved populations: persons of color (C), persons with disabilities (D), and persons over 65 (S). Job Descriptions for Board Members. Board’s Strategic Plan. Current Secretary of State Corporate Annual Report. One (1) copy only. One copy only of any printed supplemental information. Provide no more than five (5) pieces which may include books, brochures, printed website pages, programs, newspaper/magazine articles, press releases, etc. (No CD’s or DVD’s). These will not be returned. Also include (if you are a first-time JAC Grant applicant): IRS letter of determination. One (1) copy. Charter for the State of Tennessee. One (1) copy. Organization’s current Bylaws. One (1) copy. (Rev. 3/3/2011) FY2012 JAC Grant Application 11