2020 Letter of Intent - Impact 100 Cincinnati

ORGANIZATION INFORMATION

Organization Name

Legal name (if different)

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Phone (Please Format as (XXX)XXX-XXXX)*

Employer Identification Number (EIN)*

Website Address*

example: http://www.yourwebsite.com

LOI Contact Name*

First Last

LOI Contact Title*

LOI Contact Phone Number (Please Format as (XXX)XXX-XXXX)*

LOI Contact Email *PLEASE MAKE SURE YOU HAVE ACCESS TO THIS EMAIL AS CONFIRMATION/COMMUNICATION WILL BE SENT TO THIS ADDRESS*

Enter Email Confirm Email

Executive Director Name*

First Last

Executive Director Title*

Executive Director Phone (Please Format as (XXX)XXX-XXXX)*

Executive Director Email *PLEASE MAKE SURE YOU HAVE ACCESS TO THIS EMAIL AS CONFIRMATION/COMMUNICATION WILL BE SENT TO THIS ADDRESS*

Enter Email Confirm Email

Nonprofit year founded*

Organization's annual operating budget*

Mission and vision statement*

List of counties served by the Organization*

To choose multiple counties, please hold "Control" [Ctrl] or [Command] and click additional counties with your mouse.

If other, please indicate which counties outside those listed above will be served by the organization:

Upload IRS 501(c)(3) or 509(a) qualification letter

Please upload your qualification letter. Only a PDF file format is acceptable. If you have any difficulty, please fax a copy of your letter to 513.563.9743.

GRANT FOCUS AREA

Grant Focus Area Information - Please determine which grant focus area you will designate for your application. You must choose ONLY one.*

PROPOSAL SUMMARY

Project or program title*

2-3 sentence summary description of project or program*

Type of Request*

To choose multiple types, please hold "Control" [Ctrl] or [Command] and click additional counties with your mouse.

Total proposed budget for project or program*

List of counties that will be served by the project or program*

To choose multiple counties, please hold "Control" [Ctrl] or [Command] and click additional counties with your mouse.

If other, please indicate which counties outside those listed above will be served by this project or program:

PROPOSAL NARRATIVE

1. What specific need does your project or program address? Do you observe any disparities in these needs with respect to race/ethnicity, gender, (dis)ability or other marginalized groups?*

2. How does your proposed project or program impact the need described above (i.e., what does it do)? Please address how this project supports your organization's overall mission.*

3. Who is the target population for your project or program? Include the number of individuals you expect to serve and the anticipated impact. What are the demographics (race/ethnicity, gender, (dis)ability, etc.) of those you expect to serve?*

4. What are the measurable goals this project or program hopes to achieve?*

5a. Describe how Impact 100’s grant money will be spent.*

1. Please enter the line item & total dollars that will be spent per line item.
2. Click on the plus sign at the end of the row to add additional rows.
3. Line items should total $100,000.

Line Item	Dollar Amount

5b. Describe how Impact 100's grant money will be spent.

This is optional to further describe any line items above.

6. Please address what makes your project or program compelling. Has this been done in the past? What makes you confident this will be successful?*

7. If the project/program budget exceeds $100,000, how will additional funding be secured? Please be as specific as possible.*

8. How would the project/program be sustained after Impact 100 funding is exhausted, and, what can Impact 100 do to help you reach those goals?*

AUTHORIZATION

The following questions are for internal use only and will not be shared outside of the Board of Impact 100.

The Organization agrees that the Impact 100 Grant will be utilized within three years from award date.*

Yes
No
Unsure

By submission of this Letter of Intent, I confirm that the Executive Director and/or Board President are aware that this LOI request is being submitted.*

Yes
No
Unsure

The organization does not have current or pending legal conflicts.*

By submitting the LOI, you are agreeing to disclose any current or pending legal conflicts via an email to grants@impact100.org at any time during the grant review cycle.

Our organization does have current or pending legal conflicts.
Our organization does NOT have current or pending legal conflicts.

Please describe the current or pending legal conflict.

Please hit SUBMIT only when you have completed the LOI. A confirmation email will be sent to the email addresses submitted.

If no email confirmation is received from grants@impact100.org within 1 hour please check your junk mail or spam folder.