Osteopathic Heritage Foundation 2008 Capital Campaign Initiative Letter of Intent Application
Please download the Letter of Intent Application form and type the required information in the spaces provided below. Interested organizations must complete and submit, via email, the Letter of Intent to Kerry Shaw at kshaw@ohf-ohio.org no later than August 15, 2008. The Letter of Intent should by typed in 12-point font, single spaced with 1-inch margins, and Section Three should not exceed 3 pages. Please include the name of the organization submitting the Letter of Intent in the subject line of the e-mail. Please contact Kerry Shaw, Grants Manager, at 614-737-4368 or kshaw@ohf-ohio.org with questions. Section One: Organization Information Applicant Organization Information Organization Name Street City State Zip Code County Main Phone Main Fax Web site Complete Mailing Address, if different than Physical Address Primary Contact for Applicant Organization (President/CEO) Last Name First Name Middle Initial Prefix Suffix Email
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Title Phone Fax Primary Contact for Application (if different than above) Last Name First Name Middle Initial Prefix Suffix Email Position Title Phone Fax Organization and Complete Mailing Address, if different than Applicant Organization Fiscal Agent Organization Information (if different than Applicant Organization) Organization Name Street City State Zip Code County Main Phone Main Fax Web site Primary Contact for Fiscal Agent Organization (President/CEO) Last Name First Name Middle Initial Prefix Suffix Email Title Phone Fax Financial Information (To be complete by the Fiscal Organization) Budgeted Expenses for Current Year $ Legal Organization Name, as listed on IRS letter Tax ID # (EIN) Date of IRS letter
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Tax Status and Designation: 501(c)3, 509(a)1, 509(a)2, 509(a)3, Agency of the State, etc. Please be sure to include all designations listed on the IRS. NOTE: The Osteopathic Heritage Foundation will not, except under unusual circumstances, provide a grant or event sponsorship to an applicant that is designated as a supporting organization as defined by the Internal Revenue Service or within the 2006 Pension Protection Act. The Osteopathic Heritage Foundation reserves the right to review the corporate documents of the parent corporation and the applicant organization to determine supporting organization status.
Check one box: No, the applicant organization is not a supporting organization as defined by the Internal Revenue Service or within the 2006 Pension Protection Act. Yes, the applicant organization is a supporting organization as defined by the Internal Revenue Service or within the 2006 Pension Protection Act.
Section Two: Request Information Project Title Total Capital Campaign Goal Amount requested from OHF Date of Request Brief Description of the Capital Campaign; one (1) sentence Campaign Start Date Campaign End Date Population to be Served Number Served Currently Anticipated number of Clients to be served 12 months after Capital Campaign Goal is achieved Percentage of the current population served that are Franklin County residents Percentage of Board of Directors who have donated to the Capital Campaign Has the organization previously received capital campaign support from OHF? (Please indicate Y for Yes, N for No) Has the organization completed an independent capital campaign feasibility study? (Please indicate Y for Yes, N for No) If yes, to the above question, please provide the name of the independent firm that conducted the feasibility study.
$ $ To
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Does your organization have a portrait on The Columbus Foundation’s PowerPhilanthropy? (Please indicate Y for Yes, N for No) Geographic Area Served by the Project/Program (Please indicate all that apply) State of Ohio Athens Delaware Fayette Franklin Jackson Knox Madison Meigs Perry Pickaway Union Vinton Specific Project Type (Please indicate all that apply). Capacity Building Capital Program Fairfield Hocking Licking Morgan Ross Washington
Other
Section Three: Capital Campaign Information 1. Describe the organization and the programs and services provided. 2. Describe the population(s) served and the geographic service area of the organization. 3. Describe significant results achieved by the organization in the past three years, especially those related to the proposed capital campaign. 4. Describe the overall need for and intent of the capital campaign, including campaign components: new building construction, major improvements/renovations to an existing facility, and/or acquisition or enhancement of technology, furnishings, equipment and/or vehicles. 5. Describe how vulnerable populations will benefit from the proposed capital campaign improvement(s).
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Section Four: Committed and Potential Funders Please complete following chart, add rows as needed. Committed Funders Organization/Individual Name
Committed Amount
Date of Commitment
Potential Funders Organization/Individual Name
Potential Amount
Anticipated Date of Decision
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