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Form 5471 Checklist document sample
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Summer Youth Program Fund
2011 Grant Application Checklist
Organization Name:
Program Name:
Required Application Materials
Item #1 – 2011 Grant Application
Item #2 – Board List (single sided) including occupations and telephone number. Note officers.
Item #3 – Organization Budget for the current fiscal year indicating income and expenses
Item #4 – 501(c)(3) determination letter for applicant organization or sponsor
Copies and Submission Information
Applications must be received by Lilly Endowment and The Indianapolis Foundation by
12:00 noon on December 10, 2010.
For consideration by Lilly Endowment Inc. submit: For consideration by any other SYPF Funder submit:
One Original with all Items #1-4 listed above Items #1-3 at www.summeryouthprogramfund-indy.org
Two copies of checklist Items #1-3 listed above
Other SYPF Partners Include:
Christel DeHaan Family Foundation; Clowes Fund,
Inc.; Eli Lilly and Company Foundation; City of
Indianapolis DMD/HUD; Hoover Family Foundation;
The Indianapolis Foundation; JPMorgan Chase
Foundation; Lumina Foundation for Education; and
Nina Mason Pulliam Charitable Trust.
Attention: For electronic submission assistance, contact:
Barbara S. DeHart Mary Johnson
Lilly Endowment Inc. The Indianapolis Foundation
2801 N. Meridian Street 615 N. Alabama Street, Suite 119
P.O. Box 88068 Indianapolis, Indiana 46204
Indianapolis, IN 46208-0068 317-634-2423, ext. 554
317-924-5471 maryj@cicf.org
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Applications may be electronically submitted or mailed/dropped off prior to the December 10 . Applications that
are dropped off prior to deadline can be left with the receptionist at Lilly Endowment.
Funder Exclusions
I do not want the following funders to consider the 2011 SYPF grant request. (Check all that apply).
City of Indianapolis/Dept. of Metropolitan Development/HUD
Requires grantees to report client demographics including income, ethnicity, female headed households and census
tracts. City funds are paid on a reimbursement basis with supporting documentation. An organization must be able to
produce an audit, compilation, or 990 upon request to be considered for funding. Signed copies of time sheets are
required to receive fund reimbursement. Organizations must be able to demonstrate serving low-to-moderate income
households.
Hoover Family Foundation
An SYPF grant will be considered as an organization’s one and only grant for the calendar year. An organization must
be able to produce an audit, compilation, or 990 upon request to be considered for funding.
Nina Mason Pulliam Charitable Trust
An SYPF grant will be considered as an organization’s one and only grant for the calendar year. Note: Nina Mason
Pulliam Charitable Trust grant recipients will be required to send a copy of their SYPF final grant report and supporting
documents directly to Nina Mason Pulliam Charitable Trust.
The Clowes Fund
An SYPF grant will be considered as an organization’s one and only grant for the calendar year.
Summer Youth Program Fund
2011 Grant Application
APPLICATION COVER FORM
Applicant Organization Contact Information
Organization Name:
EIN (tax exempt #):
Mailing Address:
City: State: Zip:
Telephone: Fax: Website:
Executive Director/Authorizing Official:
Organization Grant Contact Name and Title:
Grant Contact Telephone: Grant Contact Email:
Sponsor Information (If your organization is not a 501(c)(3) not-for-profit, an eligible grantee is required.)
Organization Name:
EIN (tax exempt #):
Mailing Address:
City: State: Zip:
Telephone: Fax: Website:
Executive Director/Authorizing Official:
Payment Information (If a grant is awarded, indicate where the grant check should be mailed. If using a sponsor, the
grant check must be payable to the sponsoring organization.)
Payee (Organization) Name:
Payee Contact Name and Title:
Grant Request Summary
Program Name:
Program Category (Check one): Daily Enhancement/Special Project Overnight Youth Employment
Program Emphasis: (select two primary areas)
Academic Enrichment Arts/Culture Childcare/Recreation/Social Development College Access and
Success
Environment/Nature Health/Wellness/Sports Job Readiness Social & Leadership Development
A. Total Summer Program Budget (TSPB) $
B. Cash contributions committed to date $
C. In-kind contributions committed to date $
D. Total dollars committed to date (B+C) $
E. % of Total Summer Program Budget committed to date (D divided by A) %
Request to Lilly Endowment Inc. $ % of TSPB %
Request to all other SYPF Partners $ % of TSPB %
Endorsement
I confirm that this 2011 Summer Youth application is complete and all required attachments and copies are included. I
have read the policy on Page 4 of the application instructions and understand that an incomplete application may cause
the submitted application to be ineligible for review. The board of directors has approved the submission of this
application. Signatures below verify that the board of directors and chief executive officer have approved the submission
of this application. If submitting electronically, a signature is not required.
___________________________ ____________________________________ ______________________
Executive Director Signature Board Chair Signature Date
ORGANIZATION PROFILE
Organization History and Overview
Year organization was established:
Organization Mission Statement:
Provide a brief description of the purpose of your organization:
Describe any significant changes in your organization over the past 12 months. (Significant changes may
include leadership, funding, location, or service delivery strategies).
Describe the current economic climate for your summer program and what are you doing to address these
challenges.
Organization Financial Information
Total annual organization budget for the current fiscal year $
Fiscal year (month/year) to
SUMMER PROGRAM OVERVIEW AND BUDGET
Briefly describe your summer program and the need it addresses.
Geographic area(s) to be served (specify neighborhoods, school districts, townships or boundaries).
Frequency and Duration of the Program
Program Start Date (month/day) Program End Date (month/day)
2011: 2010: 2009:
Total number of weeks the program will (has)
operate(d)
Total number of days the program will (has)
operate(d)
Number of hours per day the program will (has)
operate(d)
Number of sessions/program cycles per summer
Program will (has) operate(d) extended hours
Yes No Yes No Yes No
after 5 p.m. or on weekends
Please explain any variation in frequency and/or duration of program from 2010.
Participant Ages
Indicate the total number of unduplicated youth projected to be served in each of the following age categories. (The
numbers indicated in each age category should equal the total number of unduplicated youth the program will serve
indicated in the Participant Data section below.)
Age 4-5 Age 6-8 Age 9-10 Age 11-13
Age 14-16 Age 17-18 Age 19+
Projected Participant Data
Total number of unduplicated youth the program will serve the entire summer (count each child
once regardless of number of days attended)
Average number of youth expected daily
Percentage of summer youth that reside in Marion County
Percentage of summer youth that receive a free or reduced lunch
Percentage of summer youth expected to be male
Percentage of summer youth expected to be female
Percentage of summer youth with disabilities (mental and/or physical)
Summer Program Attendance Projected Actual # on Waiting Lists
2009
2010
2011
If you did not operate a summer program in 2009 or 2010, please indicate N/A
Program Fees
Program Fee Per Child $ Per Day Week Month Entire Summer
Additional Fee For Multiple Children $ Per Day Week Month Entire Summer
How does your program accommodate those who cannot afford your fees, field trip expenses, or other costs?
During your 2010 summer program, what percentage of youth received reduced fee or full scholarship support?
Summer Program Site Locations
Building Name Street Address City
Summer Program Collaborators
If applicable, describe the primary collaborations or shared activities with other nonprofit, for-profit, or government
agencies. Be specific in describing the roles of each organization in delivering the program. Indicate “C” for committed
program collaboration or “P” for potential program collaboration.
Organization Name Role or Activity Contact Name & Phone C or P
SUMMER PROGRAM ACTIVITIES
In the expandable table below, please provide information about your program activities and proposed outcomes. Please
limit responses to this page.
Program Activity Frequency Specific Activities
Example: 3 times week
Remedial Education 2 hours per day Remedial math and writing classes
List your summer program’s expected outcomes and evaluation methods. Outcomes should be specific and measurable.
Program Outcome Evaluation Method
Example: 40 students will become better problem solvers. Instructor monitoring and observations
Example: 75% of the children will increase their math and
reading skills. Pretest and post test
Does your summer program plan to:
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Enroll youth in 6 – 8 grades in the Twenty-first Century Scholars program* Yes No
If not, please explain:
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Assist youth in 6 – 8 grades with completing a graduation plan** Yes No
If not, please explain:
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Assist youth in 9 – 10 grades with completing a career/course plan** Yes No
If not, please explain:
*For more information regarding the Twenty-first Century Scholars program, please click on the link that has been provided or visit:
http://www.in.gov/ssaci/
**For more information regarding completing a graduation or career/course plan, please click on the link that has been provided or visit:
www.learnmore.org
How will youth, parents, and partner organizations participate in your evaluation?
What did you learn from your program last summer, and how did it affect your plans for this year?
If your program provides academic enrichment:
Please describe how you assess each student’s math and reading skills:
Does your program plan to provide student progress information to schools? If so, how?
Summer Program Staffing
Ratio of daily volunteers to daily number of participating youth: :
Ratio of daily paid program staff to daily number of participating youth: :
Ratio of total volunteer and paid program staff to daily number of participating youth: :
Show the breakdown of staff salaries (don’t include the hours for staff assigned to duties unrelated to the
summer program):
# Full Time Equivalent Staff* Subtotal of Summer Salaries
Administrative personnel $
Paid program staff $
Youth salaries and stipends $
Volunteers
TOTAL*** $
* A full-time staff is considered around 40 hours a week. Someone serving 10 hours a week would be the
equivalent of .25 of full-time.
** Residential programs should substitute total number of days worked.
*** Please carry the total figure for salaries over to the salary line item on the budget page.
How many licensed teachers does your program plan to employ?
If your program will employ youth or utilize stipends for youth, please describe the positions they will hold.
Do you provide training for your summer program staff on the following?
First Aid Training Yes No
Child Abuse Identification and Reporting Yes No
Appropriate Disciplinary Techniques Yes No
Age and Developmentally Appropriate Activities Yes No
Cultural Competency Yes No
Describe how your organization addresses issues of safety and liability in each of these areas:
Building Codes:
Transportation:
Food Handling:
Personal Liability in Conduct of Staff:
Criminal Background Checks:
Staff/Student Ratio: :
PROJECTED SUMMER BUDGET AND NARRATIVE
Projected Summer Program Income
Cash In-Kind Total
Request to Lilly Endowment Inc. $ $
Request to all other SYPF Partners $ $
Other foundations $ $ $
Corporations $ $ $
Faith based institutions $ $ $
Government $ $ $
Individuals $ $ $
Program fees $ $ $
Other: $ $ $
TOTAL* $ $ $
* Total income total must equal total expenses
Potential or Committed Funding sources (Do not include funders in the SYPF collaborative)
*Indicate “C” for committed sources
of funding, “R” for requested but not
Cash In-Kind committed sources of funding, and
Contributor Amount Amount “P” for potential sources of funding.
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Projected Summer Program Expenses
Cash In-Kind Total
Adult Salaries $ $ $
Youth Salaries & Stipends (age 22 and under) $ $ $
Transportation $ $ $
Rent and Utilities $ $ $
Equipment $ $ $
Program Supplies $ $ $
Admission Fees for Field Trips $ $ $
Meals and Snacks $ $ $
Awards/Recognition $ $ $
Professional Development/Training $ $ $
Other: $ $ $
Other: $ $ $
TOTAL* $ $ $
* Expense total must equal income total
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