Grant Application Form for Community Projects
Please fill out the form completely and attach any other relevant documentation when submitting it.
Recipient organization: _________________________________________________________________________
Address (es): __________________________________________________________________________________
Corridor (s): PAP SM CAP
Email (s): _____________________________________________________________________________________
Phone (s) / Fax: ( ) _____________________________________________________________________________
Name and title of the person completing the questionnaire: ______________________________________________
How were you informed of the LEAD program?
Newspaper ( )
Website ( )
Info session ( )
Partner Organizations ( )
Other (
)
1- General Information
1.1 Type of Organization:
Non-profit ( )
A profit ( )
Other ( )
If "other" Please explain
_____________________________________________________________________________________________
1.2 Type of activities and projects of the organization:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
1.3 The organization has a legal status?
Yes ( )
No ( )
(If the answer is yes, please attach a copy of the authorization of operation)
1.4 The organization exists since how many months or years? ________________________________________
1.5 How is the organization involved in the community? (Who are the beneficiaries, how and at what level?)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
1.6 What is the involvement and community contribution within the organization?
_____________________________________________________________________________________________
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_____________________________________________________________________________________________
_____________________________________________________________________________________________
1.7 Is the organization affiliated with other associations or federations?
Yes ( )
No ( )
(If the answer is yes, please list these other associations or federations)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
1.8 Is the organization supported by any organization or person from the Haitian Diaspora?
Yes ( )
No ( )
(If the answer is yes, please provide the name and contact info of the person or organization)
_____________________________________________________________________________________________
2-
Financing
2.1 The organization seeks a grant of how much from LEAD? (Limit $ 10,000 USD)
_____________________________________________________________________________________________
2.2 Is the organization able to give a matching of $ 3 for each $ 1 requested from LEAD?
Yes ( )
No ( )
(If the answer is yes, please describe the nature of your counterpart (cash, in kind, donation, diaspora contribution
etc.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2.3 The organization received funding from other organizations during this fiscal year?
Yes ( )
No ( )
If the answer is yes, what are the names of other donor organizations? What is the amount, date and duration of this
funding?
_____________________________________________________________________________________________
2.4 Describe the “use of funds” requested from LEAD (purchase of equipment, construction, etc.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2.5 Please specify the project implementation duration in weeks or months. (Please note in figures)
(__) Weeks
(__) Month
2.6 Please provide details on your project different funding sources in the table below:
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(N.B. Counterparts in kind can be also evaluated and noted in this table)
Sources of Funding for the Project
Amount (in $ US)
LEAD: *
Counterpart 1: __________________
Counterpart 2: __________________
Counterpart 3: __________________
Counterpart 4: __________________
Counterpart 5: __________________
TOTAL
3- Personnel
3.1 How many employees / members does the organization have? _____________________________________
3.2 The organization she has a general policy for its staff (employees / members)?
Yes ( )
No ( )
3.3 Each employee / member he has a contract and a description of specific spots?
Yes ( )
No ( )
3.4 The management staff is made up of whom? (Please list below)
Name
Title
Email
Telephone(s)
4- References
Please provide the name and telephone two credible references in your community (Notable, priest, pastor,
Community Organization, etc.)
Reference 1 Name: ________________________________________ Tel: _________________________________
Reference 2 Name: ________________________________________ Tel: _________________________________
I certify that the information provided is correct and true.
Done in (town/country) _________________________________
On the (date) _________________
_____________________________________________________________________
Name & Title
_____________________________________________________________________
Signature & Date
Received at PADF/LEAD on: _________________________
By: _______________________________
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