Rockwell Collins Charitable Corporation Grant Application

Date of Application:

Grant Application

Organizational Information

Legal Name of Organization Applying: (Should be the same as on IRS determination letter and as supplied on IRS Form 990.)

Organization Common Name (if different than legal name):

Address: City: State/Prov.: Postal Code:

Phone: Fax: Website: (Include Area Code,where applicable.)

Executive Director/CEO: First Name: Last Name Title:

Phone: E-Mail:

Grant Writer/Contact Person: First Name: Last Name Title: (If different from Executive Director.)

Phone: E-Mail:

Federal Tax ID# : Request Information

Project/Program Title:

Purpose of Grant (one sentence):

Request Amount: $

Signature Information

Chair, Board of Directors: ______Date: ______

Type Name & Title :

Executive Director/CEO: ______Date: ______

Type Name & Title:

The applicant, by applying for funds, hereby certifies that should a grant be made, the funds will be used in compliance with all applicable antiterrorist financing and asset control laws, regulations, rules and executive orders. The recipient further agrees to take all reasonable steps to ensure that any individual, entity or organization expected to receive the funds is not on any list of suspected terrorists made readily accessible by the Government of the United States.

of 3 Rev. 14 (2/23/2010) Grant Application Narrative Information Required Please provide in order listed below and do not exceed three pages

Request Summary  Amount of request and one-sentence description of the grant.

Project Description In 50 words or less, describe proposed project including how, specifically, Rockwell Automation Charitable Corp. funds will be used.

Success Measures In 200 words or less, provide success measures and method of measurement/outcomes. Include linkages or collaboration with other organizations and how they will help to achieve outcomes.

Funding Considerations Describe plans for obtaining other funding needed to carry out the project/program, including amounts requested of and /or received from other funders.

List Rockwell Automation employees actively involved with organization, noting whether board member or volunteer.

______Progress Report for Previous Grant

Last grant amount, title/purpose and date made.

Summarize overall organization progress made during the year.

Report on success measures as outlined on grant application that was submitted.

Provide opportunities for improvements in the organization/project for the future.

Provide an itemized project budget including how our funds were used.

Include any information on how your organization has adapted to the changing economic climate (i.e. staff, program, budget, etc.).

of 3 Rev. 14 (2/23/2010) Completed Application Must Include:

Most recent audited financial statements including notes. Current list of organization’s officers and directors. An itemized project budget. The organization’s actual income statement for the past fiscal year, identifying the organization’s principal sources of support. Statement should indicate amount of expenses relating to program services. The organization’s operating budget with projected income and expense budget for the current fiscal year, identifying the project revenue sources. Budget should indicate amount of anticipated expenses relating to program services.

Please email completed grant application to: [email protected].

Send attachments (if any) with copy of application to: RA Charitable Corp Administrator 1201 S. Second Street Milwaukee, WI 53204

For more information, visit Rockwell Automation’s web site: www.rockwellautomation.com

of 3 Rev. 14 (2/23/2010)