Peter C. & Emajean Cook Foundation

Operating 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.

Fiscal year end for which you are requesting funds? Click or tap here to enter text.

Have you received funding from the Cook Foundation in the past 10 years? ☐YES ☐ NO

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. (Character limit 747)

What is the planned impact of this grant? What are your specific measureable goals and objectives for this grant? (Character limit 747)

Please note any changes or planned changes in leadership. (Character limit 747)

By policy, the maximum operating grant is limited to $50,000. Please complete using current year budget and prior year actual. Current Budget covers period: Click or tap here to enter text.

Financial Sustainability - Stewardship

Accounting Method Used	☐ Cash	☐ Accrual

Corresponding Dollar Commitment
Dollar amount requested	$ Click or tap here to enter text.
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.
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.
Estimated number of individuals served	Click or tap here to enter text.
Estimated cost per individual	$ Click or tap here to enter text.
Endowment Balance, if any	$ Click or tap here to enter text.

Five Largest Commitments to date – current year	Corresponding Dollar Commitment
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Does the organization receive non-philanthropic revenue? Please describe and give an estimated percent of operations covered by these sources. (Character limit 664)

Attachments

Please provide financial statements for the prior year. Internal summary statements are fine.

Please provide the current year budget.

Brief description of key staff, including qualifications relevant to your mission.

List of board members and their affiliations. Note board experience and diversity.

Authorization & Agreement

If you receive funding under this Grant Request, you agree to provide a written report on the use and impact of funds provided within twelve months of grant receipt.

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.