Peter C. & Emajean Cook Foundation

Capital Campaign Grant Request Form

Required for All Requests Over $25,000

Date:	Click or tap here to enter text.

Organizational Information

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Name of Organization	Legal Name if Different
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Street Address	City, State, Zip
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EIN #	Website
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Organization’s Top Executive	Email
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Contact for this Application	Email

Is your organization an IRS 501(c)(3) non-profit entity? ☐	YES	☐ NO

If no, is your organization a public agency/unit of government? ☐YES	☐ NO

If the answer to the above two questions is No – you are ineligible for Funding. Do not complete this form.

What is the organization’s fiscal year? Click or tap here to enter text.

Mission Focus/Organizational Strengths

Please state published mission statement: (Character limit 664)

Are you a Christian organization?	☐YES	☐ NO

If yes, how is the heart of Christ displayed in your work? (Character limit 581)

What other local organizations share your mission or service a similar group? Where are you able to collaborate with those organizations in ways that benefit the community and/or your service population?

(Character limit 664)

What is your organizational strength? If requesting entity were to cease operations tomorrow – what service currently provided would be missed the most? (Character limit 747)

Proposal

Provide a 2-3 sentence summary of the request and the current capital project. Attach a separate proposal document if desired. (Character limit 747)

How will the capital investment improve the community? Provide examples of efficiencies and outcomes expected. (Character limit 747)

Feel free to attach a campaign summary document and bypass these questions if covered in that attachment.

Explain your Campaign Timeline. Where are you relative to your timeline and the campaign goals. (Character limit 747)

Note:

Most capital campaign grants are multi-year. The foundation may fund up to 10% of a project, but the grant is contingent until the campaign attains 75% of goal.

Dollar amount requested from Cook Foundation	$ Click or tap here to enter text.
Budget for Project	$ Click or tap here to enter text.
Request as a % of Total	Click or tap here to enter text.
Expected Placed in Service Date	Click or tap here to enter text.
If building project, square footage of building	Click or tap here to enter text.
Estimated cost per square foot	$ Click or tap here to enter text.

Five Largest Project Funding Partners to Date	Corresponding Dollar Commitment
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Click or tap here to enter text.	$ Click or tap here to enter text.

Financial Sustainability - Operations

Accounting Method Used	☐ Cash	☐ Accrual

Current Budget covering period Enter current year end.	Corresponding Dollar Commitment
Budgeted Operating Income	$ Click or tap here to enter text.
Budgeted Philanthropic Cash Contributions (operations)	$ Click or tap here to enter text.
Budgeted Operating Expenses	$ Click or tap here to enter text.
Prior Year – covering Period Enter prior Year end.	$ Click or tap here to enter text.
Actual Income Available for Operations	$ Click or tap here to enter text.
Actual Operating Expenses	$ Click or tap here to enter text.
Change in Net Assets	Click or tap here to enter text.
Endowment Balance, if any	Click or tap here to enter text.

Does the organization receive non-philanthropic revenue? Please describe and give an estimated percent of operations covered by these sources. If non-philanthropic revenue will fund capital project, please provide approximate percentage. (Character limit 747)

Authorization & Agreement

If you receive funding under this Grant Request, you agree to provide updates at least twice/year reporting progress on both fundraising and the project. You agree to provide Foundation Staff with a tour and written report on the project and campaign results within six months of the project’s completion or the Foundation’s final grant payment, as applicable.

Name of Person Submitting Request	Click or tap here to enter text.
Phone	Click or tap here to enter text.
Email	Click or tap here to enter text.

Attachments

Please provide electronic files show project illustration, time line and expected progression.

List of naming opportunities, if applicable.

Project budget. Include memo with plans for management and sustainability at completion.