Form Center

2. Funding Criteria
   1. Must be an incorporated agency, with proof of not-for-profit status for one year minimum and not another taxing body (per Board Policy).

   2. Services provided should be of a type that a Township might otherwise provide directly or indirectly to its residents.

   3. Frequency of Township referrals and agency response to those referrals.

   4. Services provided must be available to all Vernon Township residents.

   5. Town Board members, at their discretion, may visit individual sites.

   6. A Service Agreement Contract will be provided to you after approval of your grant. This must be returned and signed by a signatory representative of your organization. Please note the request of proof of insurance with Vernon Township as additionally insured.
   
   Applications MUST be received by December 31st to be considered.

4. Agency Name
6. Contact Name
7. Contact Title
9. Agency Street Address
11. City
12. State
13. Zip Code
15. Telephone Number
16. Fax Number
18. Email Address
20. Accreditation from Professional or Government Unit
22. Brief Statement of Purpose
24. Amount Requested
25. Total Budget
27. Amount Received from Township Last Year
28. Township funding is what percentage of your total budget?
30. What percent of your operation is funded by:
32. Other Townships
33. Village
34. County
36. Federal
37. State
38. Other
    Specify below.
40. Please list townships, villages, or counties which funded your operation.
42. How many Vernon Township residents did you serve last year?
43. How many client hours did you serve to our township last year?
44. What is the total amount of clients served?
46. What is your primary service area?
48. Are programs, services, activities, and facilities provided by your agency available to residents of Vernon Township?

    1. Yes
    2. No (If no, please submit details below)
50. Programs, Services, Activities, and Facilities Not Available to Residents of Vernon Township
52. Is your operation age or gender specific?

    1. Yes
    2. No
53. If yes, who are you seeking service for?
55. Do you charge for your services?

    1. Yes
    2. No
56. If yes, do you charge on a sliding scale?

    1. Yes
    2. No
57. Please explain how charges are determined.
59. Do you use volunteers in your program?

    1. Yes
    2. No
60. If yes, how many?
61. How are volunteers utilized?
63. Please explain any major changes that have occurred in your agency in the past year.
    Examples: new personnel, programs, goals, facilities.
65. If you have been a recipient of Township funds in the past, please briefly explain how these funds were utilized.
67. Have you implemented any new fund raising efforts this year?
69. If Township funds are awarded, specifically, how would they be used?
71. Copy of Last Fiscal Year Audit*
    Please submit a copy of your organization's latest fiscal year Certified Audit
72. Documentation of Non-For-Profit Status*
    Please Submit Your Documentation of Non-For Profit Status
74. Any Additional Documentation/Additional Files
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field