The Greek Orthodox Ladies Philoptochos Society

National Greek Orthodox Ladies Philoptochos Society, Inc. Metropolis of Pittsburgh Greek Orthodox Ladies Philoptochos Society, Inc. National Children’s Medical Fund Grant Request Form This document seeks to explore your program, its history, track record and needs The deadline for electronic submittal of your grant request is Friday, May 31, 2013.

Eligibility Requirements:

In order to be eligible for consideration, all applicant organizations MUST:  Have current 501(c)(3) status from the Internal Revenue Service.  Be located in or serve populations of the Metropolis of Pittsburgh, which includes the state of Pennsylvania with the exception of Philadelphia and the surrounding area, the state of Ohio including only Northeast Ohio as far west as Rocky River and Central Ohio as far south as Columbus, and the state of West Virginia.  Address as their mission or project intent one of the Priority Issues for funding. Exclusions:

The CMF of the National Ladies Philoptochos Board will not consider requests for:

 Direct grants, scholarships or loans for the benefit of specific individuals. Projects of organizations whose policies or practices discriminate on the basis of race, ethnic origin, sex, creed or sexual orientation.

Part I: Organization Information

Name of Organization: ______

Mailing Address: ______

City: ______State: ______Zip/Postal Code: ______

Phone Number: (_____) - ______

Fax Number: (_____) - ______

Website: ______

Primary Contact: ______

Title: ______

Primary Contact Phone Number: (____) - ______Primary Contact Fax Number: (____) - ______Primary Contact Email: ______

Part II: Mission Statement (Statement of Purpose)

What is the mission of your organization? ______

How would you describe your current constituencies? ______

Which geographical locations do you serve? ______

Who currently serves on your organization’s board? ______

Provide a brief history of your organization. ______Part III: Pertinent Statistics:

Total annual budget in the last completed fiscal year? ______

How many people did your organization serve last year? ______

Number of full-time employees does your organization employ? ______

Is your organization a 501(c)(3) public charity? Yes ____ No ____

If so, please provide your organization’s Employer Identification Number (EIN)? ______

Did your organization have an external financial audit conducted in the last fiscal year? Yes ____ No ______

Grant Request Information

Project/Program Title: ______

Project Description: (Comprehensively describe the purpose of the project or program.

What issues or needs will the CMF grant help your organization address? ______

What specific outcomes or deliverable do you plan to achieve with this project? ______

How will the funds be used? ______How many children and families people do you estimate this project/program will serve? ______

How would you describe the specific constituency this grant is designed to affect? ______

What is the total estimated budget/annual cost of this specific project or program? ______

What other grants have you received for this project or initiative? ______

Please provide us with an example of how your program has enhanced the life of a child, or will enhance the life of a child if put into place. ______

Please email, fax and/or mail this information to: Helen Lavorata Director, National Office Greek Orthodox Ladies Philoptochos Society, Inc. 126 East 37th Street New York, NY 10016 [email protected] (email) 212-977-7770 (office phone) 212-977-7784 (office fax)

If you have any questions, please contact: Mrs. Rosemary Nikas Metropolis of Pittsburgh Philoptochos President 87 Walker Road Canonsburg, PA 15317 [email protected] (email) 724-745-5799 (home phone) 724-263-9843 (cell phone)