<p>Please Note: There are three parts to this Short Form Application (Cover Sheet, Application Narrative, Financial Documents). Please complete all three.</p><p>Instructions: 1. Visit our website to obtain a copy of funding guidelines or to view Frequently Asked Questions. 2. Please do not submit hand written proposals. 3. Please answer all the questions unless otherwise noted. 4. Please do not include any materials other than those specifically requested. 5. Please submit the application materials electronically to [email protected].</p><p>Resources:  Gateway Center for Giving’s MO Common Grant Application User Guide - http://www.centerforgiving.org/Portals/0/User%20Guide_FINAL.pdf  St. Louis Public Library’s Grants and Foundation Center - http://slplgfcnews.blogspot.com/  Foundation Center Guide to Proposal Writing -http://foundationcenter.org/getstarted/tutorials/shortcourse/components.html ______</p><p>APPLICATION FORMAT AND REQUIREMENTS </p><p>Cover Page. In no more than one (1) double spaced page, provide a brief organizational history, including a description of relevant accomplishments for children and youth in the St. Louis metropolitan community, if any. Organization letterhead is preferred, but not required.</p><p>Missouri Common Grant Application Short Form. Complete the application attached to this document.</p><p>Application narrative. In conjunction with the common grant short form, applicants should submit a narrative of no more than three (3), double-spaced pages with 11-point Times New Roman font and one-inch margins. Please use the outline below. In fairness to all applicants, proposals that do not follow these guidelines will not be considered for funding. </p><p>Purpose of this funding request. Please describe: a. Relevance: - What is the community need addressed by this project? - Based on the type of request (Nonprofit Organization Advocacy Grant, Collective Impact Network Capacity Grant, or Youth Organizing), please explain how this project fulfills the Selection Principles outlined in the Request for Proposals.</p><p> b. Impact: - What is the target population (demographic, geographic area, etc.) of this project?</p><p>1 - What does your organization hope to accomplish (outputs and/or outcomes)?</p><p> c. Sustainability: - Names and brief description of roles of partners on this project (if applicable). - Other than additional funding, how can Deaconess Foundation advance the aims of this project?</p><p> d. Excellence: - Why should Deaconess Foundation fund this organization? Financial documents. Please include the financial documents outlined below with your application 1. One-page project budget template found at www.deaconess.org 2. Organization’s last completed fiscal year budget, including actuals 3. IRS Determination Letter</p><p>For more information contact: Dr. Brandon D. Haynes Director of Community Engagement [email protected]</p><p>2 Common Grant Application Short Form Cover Sheet Grantmaker to whom this application is submitted: Org Application Date: Website: Applicants Legal Name (as shown on IRS Letter of Determination): Doing Business As (if different from legal name): EIN #: Address:</p><p>City: State: Zip Code: </p><p>Telephone #: Fax #: </p><p>Executive Director Phone #: (or Top Executive): (Please include prefix and title) Email Address: Main Contact(s) for Phone #: this Proposal: (Please include prefix and title) Email Address: Phone #: Board Chair: Email Address:</p><p>Applicant’s tax exempt status/IRS designation (e.g. 501(c) (Attach a copy of the IRS Letter of Determination- NOTE - this is not the state sales and use tax exemption certificate. If there has (3), 501(c)(9), etc.) been a name change, provide copies of the amended state certificate of incorporation and amended IRS Letter of Determination.) If not a 501(c)(3) organization, then who is the fiscal agent? (Attach a copy of the written agreement from the fiscal agent plus fiscal agent’s contact information and EIN.) </p><p>Organization’s mission statement:</p><p>Type of request (check one): [ ] Nonprofit Organization Advocacy Grant [ ] Youth Organizing Grant [ ] Collective Impact Network Capacity Grant</p><p>[ ] New Project [ ] Existing Project [ ] Expansion of Existing Project</p><p>3 Project/Campaign Name (if general operating, please indicate):</p><p>Proposal Summary - In 100 words or less, summarize the purpose of this request.</p><p>Funding Period Requested (be / / through / / $ specific): Amount Requested:</p><p>Total Project Budget for this $ Current Annual $ period (not required if general Organizational Budget: operating request): / / through / / Organization Fiscal Year:</p><p>Geographic Area(s) Served (include specific counties): (For this project. If general operations support, for this organization.)</p><p>List applicant’s membership of a giving federation (e.g., United Way, Arts & Education Council, Jewish Federation, Earthshare Missouri):</p><p>Agreement I certify to the best of my knowledge, that all information included in this proposal is correct. The tax exempt status of this organization, or its fiscal agent, is still in effect. If a grant is awarded to this organization, then the proceeds of that grant will not be distributed or used to benefit any organization or individual supporting or engaged in unlawful activities.</p><p>In compliance with the USA Patriot Act and other counterterrorism laws, I certify that all funds received from this funder will be used in compliance with all applicable anti-terrorist financing and asset control laws, statutes, and executive orders.</p><p>Signature, Executive Director Date (or authorizing official on behalf of the organization)</p><p>Reserved Rights. Deaconess Foundation reserves the right to: accept or reject any or all applications submitted; request additional information from any or all respondents; and contact respondents to ensure full understanding of and responsiveness to the solicitation requirements.</p><p>4</p>