Application Questions

Guidelines & Questions

Community Betterment Grant Application

Organization

Organization Name
IRS Designation
Organization Website
Federal Tax Id
Fiscal Agent Name
Fiscal Agent Irs Designation
Fiscal Agent Tax Id
If you do not have a Federal Tax Id or a Fiscal Agent please provide a brief explanation why
Is this organization under ecclesiastical or sectarian management or control, as specified in Iowa code 331.901(5)?
Mission Statement
Organization Address
Address Line 1
Address Line 2
City
State
Zip
District Number
District Supervisor
Mailing Address (if different)
Address Line 1
Address Line 2
City
State
Zip
If the organization is not in Polk County please provide a brief explanation of this organization's connection to Polk County.

Application Members

Name Title Email Phone

Purpose

Requested Amount
Project Total Cost
Project Start Date
Project End Date
Project Summary
Project Description
Describe the goals of the project and target beneficiaries
Describe how the project will be evaluated and the desired impact
List other financial and non-financial participants supporting this project and indicate level of support
State whether this project is a one-time request or if it has ongoing expenses. If it has ongoing expenses please describe these expenses
If there are other organizations providing similar projects then describe these organizations
If this organization previously received support from Polk County then indicate the year, amount received, organization name and project name

Budget Expenditures

Salaries and benefits
Number of employees covered
Fundraising expenditures
Amount expended directly on participants
Equipment/furnishing
Capital infrastructure expenditures
Other Expenditures
Total

Budget Revenues

Requested Amount
Other Public Contributors
Private Contributors
Individual Donations
Fundraising Activities
Other Funding
Total

Budget Questions

What percent of the total budget does this grant fund?
Does your firm engage an external auditing firm?
If grant funding is received, by what date will funds be expended?
Describe any family or business connections the applicant(s) have to the members of the Board of Supervisors, to their immediate families or to any County employees as specified in Iowa Code 331.342?

Documents

Filename Document Type Description

Grant Report

If applicable, describe why grant funds were used outside the stated purpose
What percentage of funds were spent outside of Polk County?
What amount of funds are remaining?
What amount of funds, if any, will be returned to Polk County?
By what date were the funds expended or will be expended?
Summary of expenditures and outcomes

Grant Report Documents

Filename Description Amount