<p> Review Application Instructions and Criteria carefully before completing this application.</p><p>Applications due to Sierra Health Foundation by 12 noon on Thursday, January 15, 2009. Responsive Grants Application __ Application Cover Sheet To complete this form, save it as a Microsoft Word document or click on the Word icon on the left of your screen. Then type into each shaded field. Use the TAB key to move from field to field, or click in each field. Limit your responses to the space provided. Applicant Information Organization Address Addres City State Zip Code Phone Ext E-mail Director Title Tax Exempt ID# Web site www. </p><p>Application Title Contact Address City State Zip Code Phone Ext E-mail </p><p>Proposed Activities Summary Information Target Age Group (Select One) General/All Ages Adults (19-54) Seniors (55+) Young Children (0-5) Youth (6-18)</p><p>Brief Description of Proposed Activities (limited to 190 characters). Grant funding will be used: To </p><p>Start Date End Date </p><p>Amount Requested </p><p>Primary Use of Funds (Select One) Shelter Energy Bills for Clients Mental Health Services Clothing Food Physical Health Services</p><p>Other: </p><p>Name of authorized 501(c)(3) or public agency officer </p><p>Title </p><p>Nonprofits: Use the organization name as it appears on the IRS 501(c)(3) determination letter.</p><p>Sierra Health Foundation 1 Geography That Will Be Affected Funded activities will take place in all 26 counties of Sierra Health’s funding region: Yes No If no, indicate in the space next to the county’s name the percentage of activities to take place there (best estimate). Alpine % Glenn % Sacramento % Stanislaus % Amador % Lassen % San Joaquin % Sutter % Butte % Modoc % Shasta % Tehama % Calaveras % Mono % Sierra % Trinity % Colusa % Nevada % Siskiyou % Tuolumne % El Dorado % Placer % Solano (eastern part Yolo % Plumas % including Fairfield) % Yuba %</p><p>Indicate whether the proposed activities serve an urban or rural area, or both (see page 1 of the Application Instructions and Criteria for instructions on determining this). Serves only an urban area Serves only a rural area Serves both urban and rural areas</p><p>What percent of people served by the proposed activities live in a rural area? (Best estimate; see page 1 of the Application Instructions and Criteria for instructions on determining rural areas.) %</p><p>Application Materials Checklist Completed Responsive Grant Application form, which includes: Application Cover Sheet form Proposal Narrative (limit to 3 pages) Budget and Budget Explanation Performance Measures table 501(c)(3) determination letter (if a public agency, please note in the field below)</p><p>Sierra Health Foundation 2 Proposal Narrative Please answer each of the following questions completely and succinctly. If providing these questions and answers in a separate document, use Arial font, point size 11, with 1½ line spacing and no less than .5” margins. Limit your Proposal Narrative to a total of three pages. The three pages does not include the Proposed Budget and Budget Explanation, the Performance Measures table or your 501(c)(3) determination letter.</p><p>1. Briefly describe your organization’s mission and history. Whom do you serve? What programs do you provide? How long have you been providing them? Include examples of ways your organization has been successful in its work, e.g., numbers served, outcomes, etc.</p><p>2. Describe how you plan to use Sierra Health Foundation funds.</p><p>3. Describe the population to be served with these funds.</p><p>4. Based on recent economic conditions, why is this funding needed? </p><p>5. If cooperative relationships are needed for the activities to be successful, describe those relationships. Have these been established? </p><p>Don’t forget to complete the Proposed Budget and Budget Explanation, and the Performance Measures table. See example Performance Measures tables on Sierra Health’s Web site at www.sierrahealth.org. </p><p>Sierra Health Foundation 3 SIERRA HEALTH FOUNDATION PROPOSED BUDGET AND BUDGET EXPLANATION</p><p>Requested from Other Funding Total Sierra Health Secured for Budget for These Foundation Activities (if Activities applicable) I. Personnel</p><p>Salaries (list position and FTE) 1 2 3 4 5 6 Payroll Taxes and Benefits Consultant Fees 1 2 Total Personnel </p><p>II. Other Expenses</p><p>Office Supplies Postage Printing/Duplicating Information/Materials Equipment Rent/Utilities Travel Miscellaneous (list) 1 2 3 4 5 Total Other Expenses Total Grant Expenses </p><p>BUDGET EXPLANATION DESCRIBE EACH LINE ITEM Shaded field will expand as you type. Explain each line item and include information on other sources of funding. Use additional pages if needed.</p><p>Sierra Health Foundation 4 Responsive Grants Application Performance Measures All grantees will be required to report on key performance measures for their grants. Fill in the table below with your best estimate of the proposed activities’ impact. These will be your goals. Use the sample Performance Measures tables posted on Sierra Health’s Web site at www.sierrahealth.org as a guide. This table will expand as you type. </p><p>Brief Description of Proposed Activities (from page 1): </p><p>Performance Measures How will the information be collected? When will the information be collected? Include who, what resources, what Show the time frame for information collected methods, etc., as applicable, for each for each activity and each type of measure activity and each type of measure</p><p>Effort: How much will you do? (List QUANTITY measures for planned activities here, e.g., how many people you will serve)</p><p>Effort: How well will you do it? (list QUALITY measures for each of your planned activities here)</p><p>Effect: What change will you produce? (list measures for each of your planned activities showing what impact you expect to have)</p><p>Sierra Health Foundation 5</p>