Online LOI - Impact100 South Jersey

Organization Information

Name of Organization

Primary Contact's Name *

First

Last

Primary Contact's Title

Email *

Email

Confirm Email

Phone *

Phone Extension

Website URL (ex. http://www.yourorgname.org) *

Organization Address *

Address Line 1

Address Line 2

City

State

Zip Code

County in Which the Organization is Located *

Counties Your Organization Services (check all that apply) *

Burlington
Camden
Gloucester
Cumberland

Year Organization Began Serving Burlington, Camden, Gloucester of Camden County *

Tax ID Number *

List the organization’s top five funding sources for the last completed fiscal year, including the names of funders and amounts.

Name of Funder 1 *

Funder 1 Amount *

Name of Funder 2 *

Funder 2 Amount *

Name of Funder 3 *

Funder 3 Amount *

Name of Funder 4 *

Funder 4 Amount *

Name of Funder 5 *

Funder 5 Amount *

What is the amount of your current board-approved annual operating budget?

Are you a 501c3 tax-exempt organization who has filed an IRS Form 990 for each of the past 3 years? Please attach a copy of your 501c3 letter from the most recent year. *

Upload your tax-exempt form. *

Have you completed independently prepared (audited or reviewed) financial statements for each of the past 3 years? *

In any of the past 3 years, has an independent accountant expressed any concerns regarding the organization’s financial health or viability? *

If yes, please explain.

Litigation/liability: is there litigation pending or threated against your organization? A recent judgment? *

If yes, please provide details.

Organization Mission

Provide the organization’s mission statement and brief history (3-5 sentences). *

Summarize the primary programs in support of the organization’s mission. *

Who is your organization’s target population? *

Information About the Project For Which You Are Seeking Impact100 SJ Funding

Project Name *

Indicate the county(s) and town(s) where the project will take place *

For which focus area of Impact100 South Jersey are you applying? *

Succinct description of the project (5-10 sentences). Please include: 1) a timetable for the project, 2) a description of how the project strengthens your non-profit and its ability to carry out its mission, 3) a list of the measurable goals and expected outcomes of this project or program. *

Is the project or program a collaborative effort? *

If yes, list all partners and briefly describe specific roles of each.

Total project amount (including $74,000 from Impact100 SJ)

Does your total project budget exceed the grant amount from Impact100 South Jersey? *

If yes, have you already secured the remaining funds? Please explain.

Letter of Inquiry Authorization

Executive Director Certification: By typing the Executive Director’s name below, you are certifying that the ED has reviewed the information provided in the Letter of Inquiry, and it is accurate and complete. *