Petsmart Application Form Canada Grant Application Adoption Spay Neuter Program Checklist of Qualifications Are

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Petsmart Application Form Canada Grant Application Adoption Spay Neuter Program Checklist of Qualifications Are Powered By Docstoc
					                           Grant Application: Adoption Spay/Neuter Program
Checklist of Qualifications
   Are you a Canadian Registered Charity-Section 5 with at least one year’s worth of positive financials, or a
   municipal animal care agency, or a tribal animal care agency?
   Are you asking for 30% of your last year’s annual income or less?
   If this is your first PetSmart Charities of Canada grant, are you asking for no more than $10,000?
   If your annual revenue last year was greater than $500,000, you will need to submit an audit.
   Exception: If your organisation is municipal or tribal, there is no audit required.

If we have funded you before:
    Did you submit your follow-up report within 18 months of your Grant Contract Agreement?

To increase your chances of funding (not required, but encouraged):
   Will the grant funds primarily go toward spay/neuter expenses? (not a requirement, but a plus)
    Do you have a solid plan for being able to fund this program in the future without PetSmart Charities of
    Canada funding?
   Have you determined an appropriate method of measurement? How will you know that this program has
    made an impact on your community?

Please only submit one grant at a time.
    If your grant application is funded, your Follow-up Grant Report is due no later than 18 months from the
      date of your Grant Contract Agreement. Once the Follow-up Report has been received, you will be
      eligible to apply for a new grant.
    Funding is never guaranteed, as the funding needs always surpass our available resources.
    If this grant is approved, keep us informed about any changes to your grant project, especially
      those that might alter your budget, as changes in how funds are to be spent need to be
      approved by PetSmart Charities of Canada in advance.


                                                             Organisation Profile
                                             (Type in the gray block -- it will expand as you type)

Organisation Name (“Applicant” agency):
Incorporation Date:
Official Organisation Address1:
City, Province, Postal:
Website Address:

Name of Organisation’s Executive Director or Equivalent:
Title:
Phone:
Email:

1
 The address you include is where all correspondence will be sent and should match the address on Canada Revenue
Agency documents and website. If your address has changed, include a copy of your Canada Revenue Agency change
of address acceptance.

Adoption s/n grant application-Canada 2010                                                               1
Grant Contact:
PetSmart Charities of Canada may need to contact this person for further information on this proposal.
Name:
Title:
Phone:
Fax:
Cell:
E-mail:

Total amount of grant funding requested: $

Human Resources
Number of paid employees: Full-time              Part-time
Total average hours per week for all employees
(example: 4 Full-time @ 40 hrs each + 1 Part-time @ 16 hrs + 1 Part-time @ 20 hrs = 196 TOTAL hours)
Number of active volunteers:
Total average hours per week for all volunteers

Financial/Governance
Date of most recent Fiscal Year end:(mm/dd/yyyy)
Year of last filed Canada Revenue T3010 form:
Total Revenue reported on your last filed T3010 form: $             .
Total Expenses reported on your last filed T3010 form: $                .

For organisations that do not file a T3010, list the total revenue and expenses from your last fiscal year-end
financial statement.
Revenue         $
Expenses        $

Did your organisation have a financial deficit last year?          Yes   No
          If yes, please explain why and how the deficit is being addressed.
Does your organisation anticipate a deficit for the current year?
     If so, please explain why and how the deficit will be addressed.
Is there any additional information you would like us to know about your financials (deficit, excess reserves,
unusually large increase or decrease in any line item, capital campaign, etc.)?

Functional Expense Detail
Total Program Expenses                                                  $
Total Management & General Expenses                                     $
Total Fundraising Expenses                                              $
Total Expenses                                                          $

Net Asset Detail
Total Unrestricted Net Assets (includes Board-designated)               $
Total Restricted Net Assets (Temporary & Permanent)                     $
Total Net Assets                                                        $




Adoption s/n grant application-Canada 2010                                                               2
Do you own or rent your property/facility?    Own             Rent          N/A
If you rent, do you lease at a reduced rate?  Yes             No
    If yes, please explain:
Do you rent from a related party (Board Member, employee, business associate, etc.)? If so, please briefly
describe the arrangement and lease expiration date including if you have a written memorandum of
understanding:
Please provide the length of the lease:
How many years are remaining on this current lease?

Have you received any grant funding in the past five years?       Yes          No
If yes, please list the largest funders excluding PetSmart Charities of Canada.
Date:                            Amount:$                    Funder:
Date:                                        Amount:$      Funder:
Date:                                        Amount:$      Funder:
Date:                                        Amount:$      Funder:
Date:                                        Amount:$      Funder:

Fundraising Programs: (check all approaches you currently utilize)
  Direct Mail
  E-mail appeals or other internet appeals
  Special events
  Membership
  Newsletter
  Garage Sales, Bake Sales, Car/Dog Washes, E-Bay Sales
  Thrift store
  Major Donor Program
  Planned Giving (Bequests, Endowments, Estates, Property)
  Grants
  Capital Campaign
  Sale of related services and products: (wellness services, pet supplies, etc.)
  In Kind Donations (printing, dog/cat food, equipment, furnishings, etc.)
  Sponsorships (corporate, cage sponsorships, sponsor a snip, etc.)
  Other: Please explain:

Type of Organisation: (check all that apply):
Species Aided
   Dogs                                                        Avian
   Cats                                                        Rabbits
   Horses                                                      Other

Services Provided                                        Organisation’s Structure
   Unlimited intake shelter                                 City, county, or tribal agency
   Limited intake shelter                                   Private nonprofit agency
   Foster network                                           Other
   Animal control
   Spay/neuter in-house or mobile clinic
   Spay/neuter services (referral agency/voucher, agreements with DVM or with other S/N clinics)
  TNR
   Other




Adoption s/n grant application-Canada 2010                                                           3
Animal information for most recent
completed fiscal year (to match                              Dogs        Cats       Other
financials)
Number of animals housed at beginning of
year. Year
Number entered (do not include DOA)
Animals adopted, transferred out and
reclaimed
Number euthanized
Balance in foster and in shelter at the end
of the year. Year



                                                      Grant Proposal Details
                                       (Type in the gray block -- it will expand as you type)

Objectives
In one sentence, what are you specifically asking for? (example: pre-adoption spay/neuter of 50 of our shelter
animals)

What do you hope to accomplish with these funds? (example: ensure all adopted pets are sterilized (or) reduce
voucher follow-up requirements)


Problem Statement
    Millions of pets are euthanized annually because there aren’t enough homes for them. While
    education of the public has had a steady increase on the rates of spaying and neutering, more
    sterilization is needed to reach the critical thresholds necessary to control pet overpopulation.
    Voucher systems for spay/neuter after adoption are a step in the right direction, but compliance
    cannot be guaranteed. To make sure our agency is not contributing indirectly to the problem, we wish
    to spay/neuter all (or more) pets prior to adoption.

How many                          Dogs        Cats In-      Other       Dogs       Cats          Other
animals were                    In-house       house      In-house       Out-       Out-          Out-
sterilized                      s/n clinic   s/n clinic   s/n clinic   sourced    sourced       sourced
through your
organisation
last year?
Your own
organisation’s
animals
Other rescue or
shelter animals
Public animals
(i.e. not in
connection with
adoption)
Free-roaming
cats (TNR)
Total


adoption s/n application-Canada 2010                                                                      4
Are pediatric animals altered?                   If yes, what age and weight do you consider to be pediatric?
Puppies:        age            weight
Kittens:        age            weight

Does your organisation ensure that all of its adoption animals are sterilized?            Yes            No
If no, why?

Under what circumstances are animals released before sterilization? (check all that apply)
  Never released before sterilization
  Too young                           Lack of kennel/foster home space
  Lack of funds for surgery           Lack of available veterinary services
  Underweight or ill                  Other

If your organisation does not sterilize all animals prior to adoption, do you use a voucher/deposit system?
    Yes    No

How do you guarantee that the animal has been sterilized? (check all that apply)
  Phone follow-up                     Mail follow-up
  Adopter requests deposit            Voucher returned from vet
  Other

Through that system, what percentage do you know for sure have been altered?
          % OR        Don’t know


Methods
What type of veterinary services do you use for your pre-adoption spay/neuter? (Check all that apply)
  Private Veterinarian -retail price            Mobile Low-Cost Spay/Neuter Clinic
  Private Veterinarian -discounted price        Clinic-in-Clinic model
  Shelter Clinic                                Transport model –also indicate what type of clinic
  Low-Cost Spay/Neuter Clinic                        animals are transported to
  MASH-sets up clinic at community site         Other

What arrangements have you made for veterinarians to do this work?
 If in private practice, what kind of agreement has the veterinarian(s) made with the organisation to
  participate in your program? What is the amount of your discount?

Estimate how many spays/neuters the requested grant money will pay for, broken down by dogs and cats.
We understand that this is only an estimate and that the final report will provide the actual numbers.

                                       Grant-funded           SPAY         NEUTER
                                        surgeries
                                          DOG

                                           CAT

Please give us a clear step-by-step picture of how the program will be implemented to achieve results.




Timeline
    Please design your proposed project/program to be completed within a 12-month period. Your Grant
    follow-up report will be due within 18 months from the date of the grant contract.
adoption s/n application-Canada 2010                                                                            5
Explain the timeline of your grant project here:


Budget
Create a line item for each separate kind of expense that will be covered by the grant funds. If you are
asking for funding to purchase an item that costs more than $500, please include a copy of the bid or quote
you received.

    Description of expense funded by PetSmart Charities of Canada grant                              $ Cost
Example: Neuter 45 cats @ $25 each                                                                   $1125




                                                      TOTAL (should be grant amount requested)   $
What is the average cost per surgery? (not including vaccinations or other treatments) $
Please use the formula of amount to be spent divided by number of surgeries, for example $10,000 to be spent
on 500 surgeries = $20 average.

If there are other expenditures associated with this project, please list them and indicate from where you will be
obtaining the funding. If none, just indicate “none”.

                                                                                          Source of funding if not
                                  Description of expense                      $ Cost
                                                                                              from this grant?
Example: Rabies vaccinations for 45 cats                                       $225      Budgeted operational
                                                                                         expense




Have you asked any other sources for the same funding you are asking PetSmart Charities of Canada for?
    Yes    No
If so, what was the outcome?


Future Funding
Help us understand your vision for this project when PetSmart Charities of Canada funding is fully spent by
answering the following questions:
Do you hope to continue the project?        Yes        No

If “yes”, will the project change and if so, how?
When and where will you obtain the funding to support this program?

If no, when will the project terminate?
Will this project have the potential to be absorbed by another organisation in your community?
     Yes            No If “yes”, please identify the organisation.



adoption s/n application-Canada 2010                                                                          6
Evaluation
 Results from the program will be collected and reported via the attached Grant Follow-Up Report and
 sent to PetSmart Charities of Canada no more than 18 months after the date of the grant contract. This
 step is a required part of this project has been successful?
How will you know whetherthe grant contract. Please review the Grant Follow-Up Report now to see
 what kind of information you should gather throughout the year. Note: Your follow up report
 must include copies of receipts for all individual purchases and procedures of $500 or more.

How will you know whether this project has been successful?


Representation of Accuracy, Compliance, and Permission to Inquire
I, the undersigned person, on behalf of Applicant, represent to PetSmart Charities of Canada, Inc. (“PCCI”)
that: (1) I am authorized to submit this application and make all representations provided in and with this
application; and (2) to the best of my knowledge, the information contained in this application is true and
accurate. On behalf of the Applicant and its officers, directors, employees and volunteers, I grant permission
to PCCI, its staff and any other designated representatives to make inquiries with, and request documentation
from, third parties about Applicant and the contents of this application, to assist in the evaluation of this grant
request.

In addition, as of the date of signing, the Applicant represents to PCCI that: (1) the Applicant is either (a) a
registered charity with the Canada Customs and Revenue Agency and that the Organisation is not a private
foundation, or (b) a city/county/provincial/tribal government entity; (2) the Applicant validly holds and maintains
all licenses, permits, and registrations, and has satisfied all similar requirements, necessary for its lawful
operation; and (3) the Applicant is in compliance with all applicable local, provincial, tribal and federal laws,
regulations and other requirements to which the Applicant is subject. The Applicant agrees to notify PCCI
promptly in writing of any change in the information herein.

Signed by Authorized Representative of the Applicant:

_______________________________                               _______________________________
Signature                                                     Title
_______________________________                               _______________________________
Print name                                                    Date




                                    GRANT PROPOSAL ATTACHMENTS
                         The items below must be submitted with this grant request.

 Financials2:
For government agencies:
If available include the “line item” from the city/county’s budget relating to the animal control department. If a
    line item budget is not used, no financials need to be submitted unless requested later.

For all non-government organizations:
    If total revenue from previous year was less than $25,000, include your most recently filed T3010 and
        include a signed treasurer’s annual report for the same fiscal year. This should consist of a copy of
        your Statement of Financial Income and Expense (also known as a Profit and Loss Statement) and a
        Balance Sheet.

2
 Examples of Balance Sheet and Statement of Financial Income and Expense (also known as “profit and loss statement)
are available at http://www.petsmartcharities.org/agencies/resources.php


adoption s/n application-Canada 2010                                                                         7
           If total revenue from previous year was between $25,000 and $499,999, include your most recently
            filed T3010 and include a signed treasurer’s annual report for the same fiscal year as your T3010. This
            should consist of a copy of your Statement of Financial Income and Expense and a Balance Sheet.
           If total revenue from previous year was $500,000 or greater:
                      o Include your most recently filed T3010 and an audited financial statement for the same fiscal
                         year.
                      o IF your most recently completed fiscal year end is different (later) from the year of your last
                         filed T3010, then also include a copy of your most recently completed fiscal year end
                         Statement of Financial Income and Expense and Balance Sheet.

 Budget Documentation:
           If not completed in the body of the application, attach a line item budget reflecting revenue and
            expenses for the project and another reflecting the use of the funding being requested from PetSmart
            Charities of Canada.
           Copies of any bids/quotes for requested items costing $500 or more

 Provincial Documentation:
      If your province requires a license or permit to house animals, please attach a copy of your current
      documentation for that purpose.

 Collaboration Support:
      If this is a collaborative project, include a letter of support from each organisation involved.

  Leadership Information:
      Please provide the following information about each of your board members, and reply “yes” or “no” to
      each of the three questions below.

                                       Name
                          Title
                     Address
  City, Province, Postal Code
                        Email
                       Phone
                   Profession
 Number of consecutive years
         serving on the board
Employee of                   Related to any other     Owner or employee, or related to owner or
Organization?                 board member or to an    employee, of any company paid by the organization
                              organization employee?   for services? (i.e. veterinary, accounting, legal,
                                                       boarding, etc.)




Adoption s/n application-Canada 2010                                                                          8
                                       GRANT FOLLOW-UP REPORTS
                     Submit these reports to PetSmart Charities within 18 months of the grant’s date.

Do not submit this report until ALL the grant funds have been expended. If you do not think all funds will be
expended by the due date, or if you anticipate any other changes to your original grant project, please contact
your PetSmart Charities of Canada program manager to discuss the reason for the delay and possibility of an
extension: canadiangrants@petsmartcharities.org.

Grant funds remaining at the completion of your project must be returned or written approval obtained from
your program manager for use of remaining funds. A revised line-item budget and completion date is required
at the time of your request. Please be aware that approval is not always given.

           Please mail these reports, the completed expense worksheet, and any required documentation to
                   PetSmart Charities, Attn: Grants, 19601 North 27th Avenue, Phoenix 85027

Today’s Date:                Date of Grant Contract:
Name of Your Organisation:
Address:
City, Province, Postal Code:
Grant Report Contact:              Phone #:             E-mail:
Grant Purpose:
Number of Animals Assisted by this Grant Project:               Species Aided:
Number of Animals you expected to assist in your original grant application:
Provide a breakdown of surgeries that were funded by this grant:
Female Cats:                 Female Dogs:
Male Cats:             _     Male Dogs:

Amount Received from PetSmart Charities’ Grant: $
Amount Spent from Grant: $

IMPACT-- The intent of this information is to show that the funded project achieved the
expected results.
      1. Provide a summary of your funded project that includes a narrative on the progress achieved. Include
         whether you met your anticipated goal.

      2. Report on whether you were able to provide all these surgeries to the desired targeted group. If there
         were problems reaching the targeted group, please describe how you dealt with those problems.


      3. Discuss any changes to the original plan or problems that occurred during the project and how you
         dealt with them.

      4. Please describe any data and anecdotal evidence of the success of your project.


Adoption s/n application-Canada 2010                                                                    9
      5. List accomplishments that were directly related to this grant, including resulting publicity, new
         collaborations, community involvement, etc.
      6. Is there a special story related to this grant that you could share with us?

      7. Do you have procedures, protocols, or other practical tools that could be used by another organization
         to replicate this project?


EXPENDITURES -- The intent of this information is to confirm that the funds were used within the
grant guidelines.

Using the expense worksheet located at http://petsmartcharities.org/agencies/docs/ExpenseWorksheet.xls,
attach detailed documentation of how the funds were expended. Include a line item for each separate kind of
expense. If additional funds were raised in support of your project, list the source and amounts raised.


For purchases or payment for services, include:
    All receipts for purchases or procedures $500 or higher
          o Include date of services (must be after grant funding is awarded/received)
    Copy of expense worksheet as described above
    Proof of invoice payment
          o Copies of cancelled checks or
          o Credit card statement and proof of payment for credit card statement with details or
          o Bank statement showing proof of payment that matches invoice
    Ensure that your expenditures match the grant budget
Done:

Required signature:
I, the undersigned person, on behalf of the Grantee, represent to PetSmart Charities of Canada, Inc. (“PCCI”)
that: (1) I am authorized to submit this impact report and make all representations provided in and with this
report; and (2) to the best of my knowledge, the information contained in this report is true and accurate. On
behalf of the Grantee and its officers, directors, employees and volunteers, I grant permission to PCCI, its staff
and any other designated representatives to make inquiries with, and request documentation from, third parties
about this impact report and the contents of this report, to assist in the evaluation of the success of the
program as outlined in the impact report.

In addition, as of the date of signing, the Grantee represents to PCCI that: (1) the Grantee is either (a) a
registered charity with the Canada Customs and Revenue Agency and that the Organisation is not a private
foundation, or (b) a city/county/provincial/tribal government entity; (2) the Grantee validly holds and maintains
all licenses, permits, and registrations, and has satisfied all similar requirements, necessary for its lawful
operation; and (3) the Grantee is in compliance with all applicable local, provincial, tribal and federal laws,
regulations and other requirements to which the Grantee is subject. The Grantee agrees to notify PCCI
promptly in writing of any change in the information represented herein.

Signed by Authorized Representative of the Grantee:

_______________________________                                _______________________________
Signature                                                      Title
_______________________________                                _______________________________
Print name                                                     Date




Adoption s/n application-Canada 2010                                                                         10

				
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