PROPOSAL DUE DATE: FRIDAY, OCTOBER 23, 2020, 4:00 P.M. MST

Before submitting your proposal, have you:

Read the Eligible Activities & General Information sheet?
Completed every question on the proposal?
SIGNED the proposal (Proposal-Page 2)?
Included: Financial Statement (Most recently audited) Management Letter (Separate from the Auditor’s Report) Agency Documentation (Refer to Agency Documentation Checklist)
Sent a signed electronic copy of your proposal to hsgrants@scottsdaleaz.gov in original Word™ format? (Please include your Agency Documentation in the email.)

This form must be checked off, completed, and submitted with proposal.

QUESTIONS? Please call Justin Boyd, (480) 312-2479

PROGRAM RELATED INFORMATION
1.	Department or Agency requesting funding:
2.	Proposal/Agency Name for use of Endowment Funds.
3.	Name, title, address, telephone number and email address of two (2) contacts:
4.	Brief description of the program, the need (community problem) and the number of unduplicated Scottsdale persons to be assisted for which these funds are being requested:
5.	Amount requested (please break out all costs):
6.	Describe how these funds will be utilized:
7.	What is the time frame that the funds will be used?
8.	What will you use to measure and evaluate the success of the activity?
9.	Would this activity/service be provided in Scottsdale? Yes No
10.	What need will be filled and at who’s benefit?
11.	Have you pursued other funding sources? (If yes, please describe) Yes No
12.	How long will the requested funding benefit this activity?
13.	Do you receive funds from other sources for this activity? (If yes, please describe) Yes No
14.	Will requested funds displace tax dollars? (for City of Scottsdale Programs only)? (If yes, please describe) Yes No
15.	Identify program collaborative partners that enhance your program’s ability to create community impact; include any innovative networking/leverage-producing partnerships. Describe how these collaborations enhance added value to program services. Be specific
16.	If your program is not recommended for Endowment funding, would you accept funding from another source with the city (i.e. CDBG, Scottsdale Cares or General Funds)? Yes No

Requested BY:________________________________________	Title:____________________________________

Date:________________________________________________

AGENCY DOCUMENTATION

The following documentation is required from all non-profit applicants.

Please label all attachments as follows:

Agency Documentation #1: Most current audited financial statement and management letter

Agency Documentation #2: Copy of IRS determination letter indicating 501(c)3 tax exempt status (if ever funded or revised)

Agency Documentation #3: Certification of Current Tax-Exempt Status of Grantee Organization (See attached)

Agency Documentation #3

CERTIFICATION OF TAX EXEMPT

STATUS OF GRANTEE ORGANIZATION

I,	, an Officer/Director of

(Organization)

hereby certify that the organization has received a ruling from the Internal Revenue Service that it is exempt from federal income tax under Section 501(c)(3) of the Internal Revenue Code and that the organization is not a private foundation as defined in Section 509 (a) of the Internal Revenue Code.

I further certify that said exemption rulings from the Internal Revenue Service are still in effect and have not been revoked or amended.

Signature

Name (please print)

Title

Date