Budget Proposal for Web Site by ixv20242


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									                                                     Proposal Summary Form
This form serves as a summary of your proposal. Please complete all fields, save, print and sign the form. Include all
required documentation listed in the checklist at the bottom of the Proposal Form and mail to the address listed below (page 4
of this document).

Section I: Contact Information
Legal Name of Organization                                                                                        EIN:
(per IRS 501(c)(3) letter):                                                                                       Date:
Contact:                                                           Title:
Address - line 1                                                   Address - line 2
City:                                            State:            Zip:                                           Country:
Telephone:                                                         Fax:
E-mail Address:                                                    Web site address:
Most Recent Fidelity Foundation Grant (if any):

Section II: Organizational Description
Provide a summary of the organization. (Limit 750 characters.)
(Additional information including: date founded, history, and mission should be provided in a separate Proposal Narrative.)

Section III: Financial Summary
Provide actual data for two prior years and your current year budget.                 Change in
                                             Operating       Operating                Unrestricted Net
                                             Revenue         Expenses                 Assets                      Change in Endowment
Prior Year Audited Income Statement          $              $                         $                           $
Most Recent Audited Income Statement             $                 $                  $                           $
(provide detail below)
Current Year Budget                              $                 $                  $                           N/A

Section IV: Financial Information from Most Recent Audited Financial Statements
a.) Earned Revenue:
    (e.g., fees for goods and services)                                                      Detail of Total Gifts and Grants   (b+c)
b.) Operating Gifts and Grants:                  $                                                     Federal $
c.) Gifts and Grants for Endowment                                                                         State $
    and Capital:                                                                                             City $
d.) Other Operating Revenue:                     $                                                  Individuals $
e.) Total Operating Revenue:         (a+b+d)     $                                               Corporations $
f.) Total Operating Expenses:                    $                                               Foundations $
g.) Operating Surplus (Deficit)       (e–f)      $                                             Total   (b+c) $
Current                                          Current                              Current Ratio: %
Assets: $                                        Liabilities: $                       (current assets/current liabilities)

Current Endowment: $                             Long-term                            Total Net Assets: $
                                                 Debt: $

Section V: Request Description
Request Type:                                 Planning Initiative            Technology Project
                                   Capital Improvement        Organizational Development                            Other
Summary of Request (Limit 750 characters):

Project / Initiative Budget:                  Amount Requested:                                      Amount Raised
$                                             $                                                      To Date: $

Section VI: Project/Initiative Funding Sources
Provide project/initiative funding detail below or on a separate sheet. Please include the following information:
Name of funder, amount of funding and status of funding (Received, Committed or Pending)

                                                                                                     Status: Received/Committed/
Name of Funder                                Amount of Funding                                      Pending
Example: XYZ Foundation                       $50,000                                                Received
                                 Total Pending $
                               Total Committed $
                                Total Received $

Provide information on any additional funding sources for this project, such as loans (bank and other),
prior year surplus, bond issues, tax credits, etc.
Other Funding Sources                         Amount of Funding                                      Status: Committed/Pending
                        Total Other Funding $

Section VII: Evaluation Plan
Summary of Evaluation Plan (How will you evaluate your project?)

Expected Results
A. Qualitative (What are the key objectives you expect this project to achieve?)

B. Quantitative (List the best performance indicators of the proposed initiative. Include at least one short-term success metric.)
Outcome Measure                                                    Current Level            1 year Goal               Long-Term Goal
Example: Increase number of people served                                  100,000                    110,000                      150,000

Section VIII: Senior Management Team and Board Membership
Provide a list of the Senior Management Team including their tenure with the organization.

Senior Management Team Member                    Role                                                       Tenure

Provide a list of board members in the lines below or on a separate sheet. Include the following information:
names of board members (Officers and Directors), their tenure on the board and their affiliations.

Board Member                                     Tenure           Affiliations

I hereby certify that the information provided herein, including the organization’s IRS 501(c)(3) exemption letter,
is accurate, complete and current.

Print Name                                                        Title

Signature                                                         Date

Submission Checklist                                                 ü
Completed Proposal Summary Form
Proposal Narrative
Itemized Project Budget
Project Funding Sources (if not itemized in Proposal Summary Form)
List of Officers and Directors with Their Affiliations
(if not itemized in Proposal Summary Form)
Current Operating Budget
Most Recent Two Years Audited Financial Statements
Current IRS 501(c)(3) Exemption Letter

Mailing Address:
            Margaret H.Morton
                Senior vice President
                Fidelity Foundation
                82 Devonshire Street, S2
                Boston, MA 02109

See the Preparing Your Proposal document for further details.


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