The Western New York Foundation
11 Summer St., Fourth Floor
Buffalo, New York 14209
Telephone: 716-839-4225
info@wnyfoundation.org

1. Name of Agency:___________________________________________Date:____________________
Address: _______________________________________City & State:__________________________
Zip:_________County:_______________ Phone & Extension________________Fax:_______________
Contact Person & Title (please print):______________________________________________________

FACTUAL INFORMATION

2. Amount of Request: $_____________________Cost of Total Project: $________________________
3. Brief Description of Project (One or two sentences):
__________________________________________________________________________________
__________________________________________________________________________________
4. Date of Board Vote Authorizing this Request:______________________________________________
5. Date of IRS tax exemption letter (Attach copy): ___________________________________________
6. Tax ID Number: ____________and Attach Copy of most recent Tax Form 990.
7. Is Agency a member a member of United Way?__________If so, most recent grant: $_______________
8. Is the United Way aware of this request?__________________________________________________
9. Government Funds and Grants in most recent fiscal year: (If more space needed Attach page)
Source Purpose Amount ___________________________________________________________________________________

10. Have you had any contact with a Trustee on this request? yes__ no__ Trustee: ____________________
11. Have you applied to any other foundations for all or part of the cost of this project? If so, list here:
(if more space needed Attach page)

Date Foundation Amount Response Amount Granted
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Please keep the Western New York Foundation notified of any changes in grants applications or funds received.

12. What requests for funds have you made to other foundations during the past eighteen months? Please provide their names, the project, the amount requested, the cost of the project and the amount granted.
13. How many non-government dollars does your Board raise yearly?______________________________

1. All documents requested on the first page of this Application.

2. THE ARGUMENT: In one to three pages, present a description of the project and the reasons for it: its importance, its costs, the benefits, and your argument to us for making this grant to your organization. If this request is for part of the project cost, or if this Foundation decides to cover a part of your request, please explain how you intend to raise the remainder of the project dollars. Please include numbers of people to benefit, and operating cost savings or increases that will result from this project if implemented. If operating costs will be higher in the future years, please identify how these costs will be covered. How will you evaluate the success or failure of this project? How have you considered collaboration with other agencies to better uses of equipment and personnel?

Exhibits: Include any exhibits you wish to strengthen your case.

3. Financials: Please include with your application:
    A. Audited Annual Report for last fiscal year or unaudited if not available.
    B. Current year budget and operating results to date.
    C. Financial forecasts highlighting any changes that will result if this Project is undertaken.
    D. A schedule of any fees charged for services.
    E. A complete copy of the most recent Tax Form 990-PF.

4. Organizational: Please include with your application each of the following:
    A. List of Board of Directors with their occupations, and an explanation of how the Board is elected.
    B. Copy of Board’s annual evaluation of the Executive Director for past 2 years.
    C. Copy of Annual Objectives set by the Board for the Agency for past 2 years.
    D. Most recent Executive Director’s annual report.
    E. Copy of President’s latest report (Top Board officer not staff member).

5. Bids for Services or Equipment: ENCLOSE Two Competitive Bids, if this application involves purchasing equipment or services.

6. Religious Affiliation. (Information needed to conform with Charter restrictions)
Circle one: Yes No

7. This application must be signed by an officer of the Board who is NOT on the paid staff.
I (We) hereby certify that should our request for funds be approved, the funds received from The Western New York Foundation will be used for the purpose requested, and no other; and at the end of one year from the date of this request, a report on the value of the grant will be provided.

Date:____________________________
Signature & Title:_____________________________________________________________________