Funding Request Checklist
Return this completed checklist with your grant application.
A one-page letter from the Health Center Board Chair on the letterhead of the organization. Letter should include the amount of the request; the name, title, and telephone number of the person with whom Healthy Houston should communicate; a statement that no change has occurred in the exempt status, purpose, character or method of the organization’s operation since it received its tax-exempt status from the IRS; and a statement indicating whether the organization has now or in the past operated under any name other than the name on the IRS determination letter.
Must be completed and include the signature of the Health Center Board Chair.
Description is limited to three pages and must include the following information:
- Description of organization’s nature of work, mission, and achievements.
- Needs statement: a statement about the issue being addressed by the proposed project, including source data if statistics or opinions are included.
- Funding requested: cost of the project and period of time to be covered by the funding.
- Project managers: list of names and qualifications of people who will be in charge of project.
- Proposed project: how project will address identified issue and what difference the project will make. If project is already underway, what has been accomplished to date?
- Target population: who will project target and how it will impact them?
- Timeline: when will the project begin and end?
- Expected milestones and outcome: changes you will be able to achieve and at what points.
- Evaluation: define how you will measure the success of your program.
- Sustainability: if project is ongoing, how will it be sustained after this funding ends?
Attach your organization’s current annual operating budget, including revenues and expenses, and amounts and sources of committed and pending funds. If requesting multi-year operating support, submit projected annual operating budget for years covered by your funding request. Sources of committed and pending funds should include names of funders and amounts awarded, pledged, or requested. Individual donations may be combined. Also include percentage of board members and/or trustees who financially supported your organization during the last fiscal year and the aggregate amount they gave. Budgets should be accompanied by a narrative describing each major item in the budget and explaining how each was determined.
- Attach a photocopy of latest determination letter from IRS regarding current tax exempt status under Section 501 C (3) or section 170 C and private foundation status under Section 509 C. Include the organization’s most recent audited financial statements. (If the organization’s financial statements are not audited, reviewed, or compiled by an independent accountant, an internally prepared financial statement may be submitted, including a statement of financial position-balance sheet and a statement of revenues and expenses, marked, unaudited.)
- Submit a complete copy of the organization’s board of directors or trustees. (If proposed project has a separate advisory group, please include all names.)
- Proof of FQHC status, or evidence of a binding action taken by the governing body stating its commitment to the development of an FQHC (Look Alike or Deemed) and its commitment to participate actively on the Community Health Center Development Committee to support the development of a coordinated system of primary care services in the region.
Attach a copy of this completed checklist showing that all required materials are included.
Mail this checklist with required documents by October 31, 2017 to:
Healthy Houston Foundation
c/0 Douglas Hidalgo
1770 Saint James Place, Suite 250
Houston, Texas 77056
Applications received via e-mail or fax will not be accepted.
Applicants will be notified when action is taken.
For more information, contact the Healthy Houston Foundation at email@example.com