Organization

Details

Organization Name

Tax Information

Federal Tax Id Fiscal Agent Name Fiscal Agent Irs Designation Fiscal Agent Tax Id If you do not have a Federal Tax Id or a Fiscal Agent please provide a brief explanation why Is this organization under ecclesiastical or sectarian management or control, as specified in Iowa code 331.901(5)? Mission Statement If the organization is not in Polk County please provide a brief explanation of this organization's connection to Polk County.

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Application Members

Name	Title	Email	Phone

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Purpose

Requested Amount Project Total Cost Project Summary Project Description Describe the goals of the project and target beneficiaries Describe how the project will be evaluated and the desired impact List other financial and non-financial participants supporting this project and indicate level of support State whether this project is a one-time request or if it has ongoing expenses. If it has ongoing expenses please describe these expenses If there are other organizations providing similar projects then describe these organizations If this organization previously received support from Polk County then indicate the year, amount received, organization name and project name Describe how the project addresses a documented need and serves a public purpose within Polk County

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Budget Expenditures

Salaries and benefits
Number of employees covered
Fundraising expenditures
Amount expended directly on participants
Equipment/furnishing
Capital infrastructure expenditures
Other Expenditures
Total

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Budget Revenues

Requested Amount
Other Public Contributors
Private Contributors
Individual Donations
Fundraising Activities
Other Funding
Total

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Budget Questions

What percent of the total budget does this grant fund? Does your firm engage an external auditing firm? If grant funding is received, by what date will funds be expended? Describe any family or business connections the applicant(s) have to the members of the Board of Supervisors, to their immediate families or to any County employees as specified in Iowa Code 331.342?

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Documents

Filename	Document Type	Description

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Grant Report

If applicable, describe why grant funds were used outside the stated purpose What percentage of funds were spent outside of Polk County? What amount of funds are remaining? What amount of funds, if any, will be returned to Polk County? By what date were the funds expended or will be expended? Summary of expenditures and outcomes

Grant Report Documents

Filename	Description	Amount