Public Health Grant Applications | Health1st Foundation

Applicant Organization(Required)

Amount Requested(Required)

Part I: Applicant Information

Is the applicant organized as a non-profit organization under state laws governing charitable organizations?(Required)

Yes

What State or Commonwealth governs?(Required)

Please provide a brief history and date of establishment for your organization:(Required)

Has your organization received a ruling or determination letter from the Internal Revenue Services (IRS) about your tax exempt status?(Required)

Yes

Please attach a copy of any such documents from the IRS:(Required)

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Accepted file types: jpg, pdf, docx, doc, Max. file size: 25 MB.

Exempt Status(Required)

Exempt

Not Exempt

Private Foundation Status(Required)

Yes, we hold an active Private Foundation Status

No, we do not hold an active Private Foundation Status

Please attach a copy of your organizations proposed budget for the year the grants funds are to be used:(Required)

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Accepted file types: jpg, pdf, Max. file size: 25 MB.

If this grant will be a substantial and material part of the total budget, attach a copy of the latest information return (Form 990 or 990-F) filed by the applicant with the Internal Revenue Service.

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Accepted file types: jpg, pdf, Max. file size: 25 MB.

Describe your organization's purpose, mission, and general activities:(Required)

Is your organization controlled by, related to, connected with, or sponsored by another organization?

Yes

Please identify this related organization (including it's mission and activities) and the nature of it's relationship to your organization:(Required)

Has your organization (or any of the organizations listed above) ever applied for or received a grant from this foundation?(Required)

Yes

Please list additional details on those applications or grant awards:(Required)

Applicant Organization's Governing Board

Please attach a document with the name, title, address and phone number for each of the members of your governing board.

Governing Board Document(Required)

Accepted file types: jpg, pdf, doc, docx, Max. file size: 25 MB.

Part II: Use of Proposed Grant

State the amount requested and explain in detail how it will be used:(Required)

State the duration of the project and any funding resources from the past, present and future:(Required)

Attach relevant documents if needed:

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Accepted file types: jpg, pdf, doc, docx, Max. file size: 25 MB.

Describe the unique aspects of the program and its relationship to other similar programs:(Required)

Give a concise description of the program showing the need or problem, the proposed solution, and the expected benefits to health care in Georgia:(Required)

Describe your plans for measuring program results:(Required)

Program Contact

Please provide the following information for the individual responsible for administering the proposed program:

Name(Required)

First Last

Email(Required)

Phone(Required)

Organization or Primary Contact Mailing Address

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

Describe this individual's experience and relevant qualifications for administering this program:(Required)

Applicant Agreement

From my own knowledge, I state the information given in Parts I and II is correct. The applicant organization has authorized me to make this application. We further agree to report our program’s progress to the foundation six months from the distribution of the grant and again in twelve months. Grantees will be required to repay any amount used outside of grant guidelines. Upon determination by The Foundation that any part of a grant has been used for improper purposes, all reasonable and appropriate steps will be taken to recover the funds illegally spent.

Name(Required)

First Last

Date(Required)

Phone(Required)

Email(Required)