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Organization: by BH3fJP


									Organization:                                    Counties Served:
Date:                                            incorporated:
Director:                                        Tax ID #:
Address:                                         City, State, ZIP:
Phone No.                                        Website URL:

Email address:
Fiscal Sponsor                                   Fiscal Sponsor's
(if applicable)                                  Tax ID #:
FS Address:                                      City, State, ZIP:
FS Phone No.                                     FS Website URL:

FS Fax No.                                       FS Email address:

Your organization MUST complete the online Eligibility Wizard in order to
submit an application. Have you completed the Eligibility Wizard on The                          YES        NO
Philadelphia Foundation's website? Click in the appropriate box to the right.

                                         Up to 8% of the organizations' budget (up to no more than
                                        $40,000) may be supported. Awards are then based on budget
Request Amount:         $               size and overall application score.
Has your organization incurred any
deficits in the past three years?                              If YES, Please briefly explain in the box provided
                                                      No       below.

     Organizational Budget*
                                              REVENUE                 EXPENSE           Surplus/(Deficit)

                       Current year
                      Previous year
                       2 years prior
                       3 years prior

*Refer to organization’s audited financials or completed 990 in reflecting revenue and expense in previous years.
Current year’s figures can be based on budget forecast.

Populations Served
What percentage of the constituency you serve or represent could be classified as low-income?
What is the methodology used to determine the figure quoted above?

Check any that apply and indicate what percentage of your constituency, where appropriate.

     Immigrants            %        Disabled             %            Terminal Illness       %
     Incarcerated           %       Seniors              %            Women                   %
     History of abuse        %      Mental Illness       %            Substance Abuse          %
     LGBTI                   %      Blind                %

    Infants (0-3)       %                 Adults          %
    Children (3-12)       %               Elderly         %
    Teenage Youth (13-19)          %

What is the total number of unduplicated individuals served or represented by your
organization's programs and services in the past year?

Mission of organization:

Overview of organization's history, programs and activities:

4. Financial Information
Describe your business model: asset allocation, sources and types of income, cost centers,
revenue generating activities (earned and contributed).

How is your capital structure related to your financial planning? (For instance, if you own or
manage a building, do you maintain a building reserve fund?)

Describe the checks and balances used in ensuring segregation of financial responsibilities.

Briefly describe the role of your board in understanding and contributing to the financial
condition of your organization.

Describe your current financial systems: your budget development process, budget forecasting,
accounting systems, and systems for cash flow, investments, budget reviews; and staffing for
this work. What is the role of volunteers?

5. Outcomes
Describe how your organization evaluates the success of its programs, include how data is
collected and how often. If you evaluate your program, describe how the organization uses that
 evaluation to identify strengths and weaknesses in the program.

Please provide an explanation.

 High Performance Standards for Leadership Capacity
 Core Program Development Stage

  Leadership                                                                       Organizational
   1. Organization has established a small homogenous board.                         YES            NO

   2. Board develops a clear purpose and vision that is understood by itself,        YES            NO
 staff, and volunteers.

   3. Board plays a hands-on role in overseeing and managing the                     YES            NO

   4. Board conducts an informal performance review of the chief executive.          YES            NO

   5. Volunteer or staff person founds organization or board hires staff leader.     YES            NO

   6. Staff leader is entrepreneurial and adept at establishing and growing the      YES            NO

   7. Board hires chief executive.                                                   YES            NO

   8. Board appoints board chair.                                                    YES            NO

 Use this space for any other comments you may have on your organization's leadership capacity.

 High Performance Standards for Adaptive Capacity
 Core Program Development Stage

Adaptive                                                                          Organizational
   1. Organization has informal, hands-on ways to identify constituent needs--       YES           NO
such as talking extensively to a network of community leaders and potential
   2. Organizational leaders have periodic, reflective conversations about how
                                                                                     YES           NO
the organization is performing and identifies basic ways to improve the
management and governance of the organization.
   3. Program volunteers and staff have periodic reflective discussions about        YES           NO
what seems to be working with the programs and why, keeping track of
anecdotes and stories that relate to outcomes.
   4. Staff and board have periodic reflective conversations about what was
learned during informal needs assessment, organizational assessment,                 YES           NO
program evaluation, and other sources, and how it relates to possible
organizational improvements.
 5. Organization develops simple systems for storing, organizing,                    YES           NO
disseminating, and using its knowledge.
  6. Organizational leaders create a strategic thinking piece with a 2-year          YES           NO
horizon that explains how it will start up the organization.
 7. Organization has a simple plan for generating revenues from at least one         YES           NO
major funding source.

   9. Organization forms relationships with other groups and begins informally       YES           NO
cooperating with some of them, such as by sharing information and making
  Use this space for any additional comments on adaptive capacity.

High Performance Standards for Management Capacity
Core Program Development Stage

Management                                                                        Organizational
  Organization has a small number of volunteers or staff and there is little or      YES           NO
  no organizational hierarchy.

  Organizational leaders establish roles for staff and volunteers and recruit        YES           NO
and hire people.

  Volunteers and staff are informally oriented, trained, and evaluated.              YES           NO
  Organization communicates informally among staff, such as by having               YES           NO
sporadic conversations and meetings.

  Staff decision-making process is informal.                                        YES           NO

  There are few or no formal personnel policies.                                    YES           NO

  Organizational leaders create a basic annual budget and meet regularly to         YES           NO
discuss how to allocate financial resources.

  Organization establishes a basic accounting system, which may be cash-
                                                                                    YES           NO
based, and creates annual financial statements that are audited internally and
approved by the board.
  Organization has adequate human resources, such as a part-time                    YES           NO
bookkeeper, to handle the financial management function.

  Use this space for any other comments you may have on your organization's management capacity.

High Performance Standards for Operational Capacity
Core Program Development Stage

Operational                                                                      Organizational
  Organization establishes basic skills to effectively provide simple programs      YES           NO
that meet the needs that it identifies.

  Organization has fundamental skills to have reflective conversations about        YES           NO
program outcomes and informally evaluate programs.

  Organization builds basic skills to develop strong connections with               YES           NO
constituents and effectively perform outreach and advocacy.

  Organization has adequate ability to market its programs and services and
                                                                                    YES           NO
communicate about its activities in simple ways, such as through word-of-
mouth and written program descriptions.
  Organization has legal skills necessary for the organization, such as for         YES           NO
 creating bylaws and articles of incorporation and obtaining tax-exempt status.
   Organization has skills to secure contributed revenue from at least one main               YES              NO

   Organization has skills to begin planning possible earned-income activities.               YES              NO

   Organization has accounting and financial management skills needed to set
                                                                                              YES              NO
 up payroll, create and manage an annual budget, establish and implement a
 simple accounting system, and create annual financial statements.
   Organization has fundamental skills to manage, operate, and maintain its                   YES              NO
 facilities, such as borrowing, subleasing, leasing, and maintaining office and
 program space. Organization has basic skills to use and manage technology,
 such as telephone, fax, and computer hardware and software.
   Use this space for any other comments you may have on your organization's operational capacity

For your application to be considered, you must include your supplemental materials.
• A copy of 501c3 designation letter
• Current year budget with detailed income sources, expenses and the most current year-to-date P&L statement
• Executive Summary of most recent Strategic/Business Plan (no more than 2 years old)
• Audits for the past three years. (If none are available, please submit 990s for past three years)
• Current list of Board of Directors and their affiliations
• Current bios of key staff members
• A current copy of the PA Bureau of Charitable Organizations Certificate
Please upload this form as well as a copy of the documents listed above to:   General Operating Support Drop Box
If you have any questions, please call Grantmaking Services 215-563-6417


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