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					THE CLUB OF HEARTS AGENCY GUIDELINES & APPLICATION Any organization seeking funding from the Club of Hearts, Inc. must adhere to the following deadlines, qualifications and guidelines. Failure to do so will result in the denial of the application. The Club of Hearts Board of Trustees makes all final decisions about agency applications. The applying organization must: - Provide direct support/relief of health and human suffering to residents in the 13county metro Atlanta area and be physically located in this area (unless previously grandfathered as a Club of Hearts-supported agency). - Be able to obtain financial support (pledged contributions) from at least 10 Georgia Power/Southern Company Services (GA) employees and/or retirees during the companies’ annual employee giving campaign. - Not be an agency on United Way of Metropolitan Atlanta’s 2007 specific care list. - Upon request, be willing to allow an onsite assessment from a Club of Hearts trustee prior to final approval of application. - Not be an advocacy group. - Complete the agency application and provide a copy of its 501 (c 3 tax certification letter and the most recent copy of its 990 tax return by March 31. - Apply annually for inclusion as a Club of Hearts supported agency. No agencies are automatically renewed. Upon approval: - Participating agencies will be included on Club of Hearts’ pledge form during its annual fall campaign. Any pledged contributions received from employees and retirees for participating agencies will then be distributed by Club of Hearts on a quarterly basis throughout the year. - Participating agencies will also be eligible to receive an annual pro rata allocation of Club of Hearts’ General Fund contributions. This pro rata allocation is included in the agencies’ fourth quarter checks. Revised January 2008

Club of Hearts Agency Application Form (2009 Campaign)
DEADLINE FOR APPLICATION IS - March 31, 2008 Return to: The Club of Hearts, Inc. 241 Ralph McGill Blvd., NE Bin 10240 Atlanta, GA 30308-3374

Name of Organization _____________________________________________________________________________ Address ________________________________________________________________________________________ City, State, Zip ___________________________________________________________________________________ Key Contact _________________________________________________ Phone Number ______________________ Title ________________________________________________________ E-mail Address______________________ Please attach 501(c) (3) Tax Exemption Letter and most recent 990 Tax Return. This information must be included to have application considered. Funds will be distributed quarterly beginning in 2009 for approved applications. Georgia Power and Southern Company employee involvement: 1. To your knowledge, does any Georgia Power or Southern Company employee (or family members of employees) receive your services? Yes _______ No _______ Number of employees served _______

2. Are there any employees (or family members of employees) of Georgia Power or Southern Company associated with your agency? Yes ______ No ______ If yes, give name(s) and explain. (Please note if any of these employees are on the Board of Directors).

I.

Sources of Income: Total Income:
Previous Year

Previous Year

Current Year Projection

$ __________ Current Year Projection $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________

$ __________

A. B. C. D. E. F. G.

Fund-Raisers Corporate Donations Grants United Way Private Sources Government Agencies Other

$ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________

II.

Expenses: Total Expenses: A. Salaries/Compensation

Previous Year

Current Year Projection

$ __________

$ __________

Number of employees
Previous Year Current Year Projection Previous Year Current Year Projection

1. 2. 3. 4.

Board of Directors Full Time Part Time Volunteer

$ _________ $ _________ $ _________

$ _________ $ _________ $ _________

________ ________ ________ ________

________ ________ ________ ________

B. Other 1. 2. 3. 4. 5. 6. 7. 8. Leases/Rents Utilities Supplies Food Medical Clothing Education Other Total

Previous
Year

Current Year

$ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________

Projection $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________

Explain:

C. Capital Explain:

Previous Year

Current Year Projection

$ _________

$ __________

III. How will the funds be used? (Please check all that apply )
A. Salaries/Compensation B. Operating and Maintenance Expenses C. Capital D. Other ________Explain ____________________________________________________ ________Explain ____________________________________________________ ________Explain ____________________________________________________ ________Explain ____________________________________________________

IV.

Questions about the organization. 1. What is your organization’s Mission Statement? we strive to be awesome in all that we do. 2. What counties do you serve? (Please check all that apply) Butts Douglas Cherokee Clayton Cobb ____ ____ ____ ____ ____ Coweta DeKalb Fayette Fulton ____ ____ ____ ____ Gwinnett Henry Paulding Rockdale ____ ____ ____ ____

3. What other agencies in your area provide similar services?

4. Are there any limitations as to who can receive your services? If yes, explain. 5. What percentage of operating per dollar are donated? _____(Previous Year)_____(Current Year Projection) 6. How many people does your organization serve annually?______(Previous Year)______(Current Year Projection) 7. How much of every dollar raised is directed to programs? 8. How much of every dollar raised is used for fund-raising and administration? 9. Please list the names of current board members:

10. Is your agency on United Way of Metropolitan Atlanta's specific care list?

V.

Please check one or more boxes below that best describe the services your organization provides.
Adults Children

Health
Major Illness - Cancer - Disease - Injuries - Disability - Substance Abuse Other: (please explain)

Human Suffering
Homeless Shelters Camps for children (Therapeutic) Foster Homes Food Bank/Soup Kitchens Other: (please explain)

Submit


				
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