Grant Application Please enable JavaScript in your browser to complete this form.Date of SubmissionName of Primary Contact *FirstLastLegal Name of OrganizationApplicants Email Address *Applicant’s Phone Number1a. Organization is listed as active on SunbizNoYes1b. Organization is a 501(c)(3)NoYesIf other type of non-profit, need explanation1c. Organizations active EIN 1d. Organization has a physical presence in Citrus CountyNoYesIf not Citrus County based, need explanation project/program and (CHIP) 1e. Organization has completed an IRS 990 within the past yearNoYes1f. Application will address at least one area of need as identified in the current Citrus County Community Health Improvement Plan (CHIP) or by CCCCFNoYes2. Is this a grant request tolaunch a new project/programexpand an existing project/programsustain an existing project/program3. Name of Project or Program4. Grant amount requested5. Applicant's program or grant administrator6. Applicant’s website, Facebook, or Instagram7. Primary address/location within Citrus County8. Years of operation in Citrus County9. Relationship of program/project to 501(c)(3)10. Description of Applicant Organization11. Applicant Organization’s Mission Statement12. List one or more Citrus County Community Health Improvement Plan (CHIP) priorities or goals to be addressed by applicant's proposal13. If a CHIP priority/goal was not identified, list one or more health or medical needs as defined in the CCCCF Grant Funding Policy to be addressed by applicant's proposal14. If a CHIP priority/goal was not identified, provide the research and supporting data for the above identified Citrus County health or medical needs to be addressed. You may also attach electronic documents of research and supporting data15a. Define the population(s) to be served in terms of characteristics, location, and numbers/prevalence/incidence. Include or electronically attach any objective data15b. Include any objective data for 15a.16. Provide overview of how project/program currently functions or how the project/program would function upon implementation17. List the first year (grant year) goal(s)18. List the first year (grant year) strategies19a. How would the project/program would be implemented, expanded or sustained during first year (grant year)?19b. Start date of grant period, 6 month benchmarks and one year benchmarks20. How will the project/program benefits/achievements will be measured and reported?21. Will the project/program be sustained or expanded beyond the initial grant year? If so, how?22a. Attached Document: Applicant organization's two most recent full year and current YTD income statements. Please break out Citrus County amounts if income statements include operations outside of Citrus CountyNoYes22b. Attached Document: Applicant organization's two most recent year end and current month balance sheetsNoYes22c. Attached Document: Applicant organization's prior year and YTD sources of revenue (if not specified in applicant's income statements)NoYes22d. Attached Document: Project/program's first year (grant year) revenue/expense budget including revenue sourcesNoYes22e. Attached Document: Most recent IRS form 990NoYes23. Does your organization commit to maintain separate revenue, expense, and funds tracking for the project/program's Citrus County operations during the grant year?NoYes24. Describe availability of any volunteers, free services, donated supplies/equipment assumed within the project/program’s operations and budget25a. Attached Document: Resume/CV of program/grant administratorNoYes25b. Attached Document: Drug-Free Workplace policyNoYes25c. Attached Document: Equal Opportunity policyNoYes25d. Attached Document: Non-discrimination policyNoYes25e. Attached Document: HIPAA or privacy policyNoYesDocument Uploads Click or drag files to this area to upload. You can upload up to 10 files. Additional NotesFor Administrator UseSubmit
