Delta Dental of New Jersey Foundation, Inc.
Grant Application—Round One
The space available on this form may be insufficient for your responses. When providing attachments, please
organize them in the same order as the items appear on this form. Also, we accept only typed grant applications.
1. Name of Organization
Address
City, State, Zip
Tax Identification Number or
Employer Identification Number
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2. Grant Contact Name
Title
Phone Number & Fax Number
Email
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3. Program Title
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4. Amount Requested
$
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5. Date Funds Are Needed
January 2014 or June 2014 (please circle one)
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6. Have you sought funding for this program from other sponsors?  YES
Please list (indicate if awards are pending or have been approved):
 NO
$
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(Organization)
(Amount)
$
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(Organization)
(Amount)
$
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(Organization)
(Amount)
7. Will you be providing additional internal funding for the program?  YES
$
 NO
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(Amount)
8. If awarded funding only in 2014, in subsequent years what percentage of your program will
be sustainable?
%
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9. Area of program interest (check all that apply to the dental program you are applying for Delta Dental funding):
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Dental Education (includes scholarship programs and children’s programs)
Dental Care for Developmentally Disabled Populations
Dental Care for Children (0-17 years old)
Dental Care for Senior Citizens (65+ years old)
DDNJ_Round One_2014
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10. If your entity is a dental clinic (only provide totals for the population(s) your grant request
will serve; answers should pertain to Delta Dental grant only):
Approximately how many developmentally disabled persons will be served:
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Approximately how many children will be served:
If your grant will be serving children, please circle what age group it will be serving:
0-3 years old/ 4-17 years old
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Approximately how many senior citizens (65+) will be served:
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If your entity is a school (answers should pertain to Delta Dental grant only):
Approximately how many students will be served:
Approximately how many scholarships (if applicable) will be awarded:
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11. We encourage you to participate in community outreach programs such as Give Kids A Smile
Day (GKAS). Please tell us if you do participate in GKAS (if applicable).  YES  NO
If there are other community outreach programs you participate in, please list here:
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12. Are you willing to provide Outcomes Reports on the use of the funds and the effectiveness
of the program?  YES  NO
13. Are you willing to accommodate an on-site visit by representatives of the Foundation, if
necessary, to review progress related to your program?  YES  NO
14. Previous grantees only need to supply updated information for the following. Please submit
your organization’s most recent 990 Form (even if we have a previous form on file).
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Mission Statement
Organizational Information
Services Provided
Affiliations
Management and Board List
A Copy of your Most Recent 990 Form (REQUIRED)
15. Please briefly describe your dental program, the population(s) it will serve, and how the
Delta Dental grant funds will be utilized (dental care, supplies, equipment, labor related,
scholarships, etc.).
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Please return grant application and supporting documents to:
Kimberly Elmore: [email protected]
OR
Kimberly Elmore, Community Relations Administrator
Delta Dental of New Jersey Foundation
1639 Route 10, P.O. Box 222
Parsippany, New Jersey 07054-0222
DDNJ_Round One_2014
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