<p> 2014 Tour/ Grant Application Form</p><p>Name of Agency: Date: Project Name for which funding is requested: 1. Agency Information Mailing Address: Program Site Address: Telephone: Fax: Website: Contact Person: Contact Person’s Title: Telephone: E-mail:</p><p>Executive Director: Date Founded: Tax ID #: Exempt Status: 501(3)(c) Govt. Agency Other Explain “Other” exempt status and any Agency affiliation with a religious, political, or larger entity on a separate sheet.</p><p>2. Agency’s Mission (2 – 3 sentences – limit description to the space provided below) </p><p>3. Agency’s Financial Data for the Past Fiscal Year</p><p>Fiscal year ending date: Gross Income for past fiscal year: $ Gross Expenses: $ % Expense Allocation for past fiscal year. Program % Administration: % Fundraising %</p><p>Explain any significant changes in Agency revenue or expenses between last fiscal year and current fiscal year (limit description to the space provided below). CSL Grant Application 9/11/2013 4. Personnel</p><p>Agency Program Specifically Total # of paid FTE employees Total # of volunteers Average staff turnover 2011-12 % %</p><p>State the current salary of the Agency Director, the Program Director for which you are seeking CSL funding, and the position and salary of the top three paid staff of the Agency. For each position, also indicate the percentage of FTE spent on the Program.</p><p>Position Title FTE % Actual Annual Salary Agency Director % $ Program Director % $ % $ % $ % $</p><p>5. Grant Request (information should reflect period 7/2013 to 6/2014)</p><p>Amount of funding requested (up to $10,000): $</p><p>Total Agency Budget: $</p><p>Total Program Budget: $</p><p>Requested funding as % of Agency Budget % As % of Program Budget %</p><p>6. Primary Service Provided (Identify the primary service provided and specify the population targeted) </p><p>(CHECK ONE BOX ONLY) After School Support Homelessness Children with Special Physical Needs Life Skills Counseling Recreation Food/Hunger/Nutrition Victims of Abuse, Violence Foster/Adopted Children Otherwise Disadvantaged Health Services </p><p>2 7. Program Information (data for program for which fund is requested)</p><p>Race/ethnicity of program participants Demographics of Participants African American % Impoverished % Asian American % Low-income % Hispanic/Latino % Moderate Income % Native American % Middle income % Pacific Islander % Undetermined % White (Non-Hispanic) % Other (please state) %</p><p>Primary language(s) of participants:</p><p>Other relevant demographic data:</p><p>8. Program Description (In an attachment not exceeding 2 pages and using 12 pt. font, please describe the distinctive goals of the Program, the selection or application criteria for participants, the activities involved and the performance measures or evaluation criteria. )</p><p>9. Use of Funds (Describe specifically how CSL funds will be used to support the Program: Salary, rent, materials/equipment, supplies; other important considerations. Use the space allotted below.)</p><p>3</p>