ROUNDY’S FOUNDATION



ROUNDY’S FUND OF THE KROGER FOUNDATIONGRANT APPLICATIONWith the merger of Roundy’s and The Kroger Co., the assets of the Roundy’s Foundation have been merged into The Kroger Foundation, and the Roundy’s Foundation is now known as the Roundy’s Fund of the Kroger Foundation.The goals of the Roundy’s Fund are to enhance the quality of life in the communities in which we live and do business by focusing giving in the area of hunger relief.Primary emphasis will be placed on organizations and programs within the territory where Roundy’s has a significant business presence and in communities where Roundy’s employees live and work. Organizations must have an Internal Revenue Service 501(c)(3) tax exemption letter.HOW TO APPLYIf your organization qualifies as a charitable, not-for-profit 501(c)(3) tax exempt organization under the Internal Revenue Service Code guidelines, is located in a community served by Roundy’s, Inc., and has a request that is specific to hunger relief, you may apply for a grant.Please follow these instructions for completing the application:Type and single-space all proposals.Provide all of the information in the order listed.All questions relative to the request must be completed fully.Submit only one copy with numbered pages.Do not include materials other than those specifically requested at this time.Do not send videotapes.Multi-year commitment requests, sponsorships or capital campaign requests cannot be considered.Submit the following attachments with the completed proposal:Complete list of the organization's officers and directors.The organization's actual income and expense statement for the past fiscal year, identifying the organization's principal sources of support.The organization's projected income and expense budget for the current fiscal year, identifying the projected revenue sources.The organization's most recent audited financial statement including notes and IRS Form 990Copy of the IRS federal tax exemption determination letterMail to: The Roundy’s FundMS-2175P.O. Box 473Milwaukee, WI 53201-0473Roundy’s Fund Grant ApplicationProvide the following grant information in this order. For your convenience, you may choose either to copy and fill out this cover summary, or create your own using the headings listed below.Date Submitted: FORMTEXT ????? Total Proposed Project/Program Budget: FORMTEXT ????? Amount Requested: FORMTEXT ?????Program Name: FORMTEXT ?????Duration of Project/Program: from FORMTEXT ????? to FORMTEXT ????? When are funds needed? FORMTEXT ?????Nature of Request: FORMCHECKBOX Project FORMCHECKBOX Program Organization Information:Name and address: FORMTEXT ?????Phone number: FORMTEXT ????? FAX Number: FORMTEXT ????? Contact Email: FORMTEXT ????? FEI #: FORMTEXT ????? Date of Incorporation: FORMTEXT ????? Chief Staff Officer/Title: FORMTEXT ????? Phone number: FORMTEXT ?????Contact Person/Title: FORMTEXT ????? Phone number: FORMTEXT ????? Board Chairperson/Title: FORMTEXT ????? Dates of organization's fiscal year: FORMTEXT ?????Organization's total operating budget for past year FORMTEXT ????? and current year FORMTEXT ????? Has the governing board approved a policy which states that the organization does not discriminate as to age, race, religion, sex or national origin? Yes FORMCHECKBOX No FORMCHECKBOX If yes, when? FORMTEXT ?????Has the organization’s chief executive officer authorized this request? Yes FORMCHECKBOX No FORMCHECKBOX An officer of the organization’s governing body must sign this application:The undersigned, an authorized officer of the organization, does hereby certify that the information set forth in this grant application is true and correct, that the Federal tax exemption determination letter attached hereto has not been revoked and the present operation of the organization and its current sources of support are not inconsistent with the organization’s continuing tax exempt classification as set forth in such determination letter.______________________________________________________________ _____________SignaturePrint Name/TitleDateEnclose all required support materials with the application (See page 1, How to Apply). NARRATIVEPLEASE PROVIDE THE FOLLOWING INFORMATION IN THE ORDER PRESENTED BELOW. REFER TO THE GLOSSARY OF TERMS AS NEEDED WHEN PREPARING THE NARRATIVE. (No more than five pages; ten point minimum; include applicant’s name on the top of each page)NEARBY ROUNDY’S OWNED STORE(S): SPECIFIC GRANT REQUEST: Amount Specifically what funds will be used forEXECUTIVE DIRECTOR: BOARD MEMBERS: Include (or attach Board of Directors List)- NamesProfessional affiliationMISSION OF ORGANIZATION: ORGANIZATION INFORMATION:Include - Goals, programs and major accomplishmentsEvidence of client and community supportSize and characteristics of the population to be servedCollaborations PROGRAM/PROJECT SUMMARY:Include:Significance/scope of the project/program and why your organization is qualified to carry it out.Goals and expected outcomes and the indicators of those outcomes.Evaluation processLinkages/collaborations usesHow does program enhance the existing services in the community?If repeat grant request – PLEASE indicate actual vs. projected goals for this program.PROVIDE METRICS ON HOW LAST YEAR’S GOALS WERE MET OR NOT MET:HOW WERE PRIOR GRANTS FROM ROUNDY’S USED:GIVE PLANS FOR PROGRAM SUSTAINABILITY:How are you broadening your donor basePlans to ensure continued fundingFINANCIAL EFFECTIVENESS OF ORGANIZATION: Percentage of incoming funds spent on programs/services: % (list general areas)Percentage of incoming funds spent on operating overhead: %(list general areas)TOP FIVE FUNDERS (with grant amounts) FROM PREVIOUS TWO YEARS:Roundy’s Fund Grant ApplicationPROJECT/PROGRAM BUDGETOrganization Name: FORMTEXT ?????PROJECT/PROGRAM REVENUETotal RevenueCommittedPendingUnited Way Allocation$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Other Federated Campaign Allocations FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Contracts (list specific sources on following page) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Grants (list sources on following page: Foundations, Corporations & Government) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????In-Kind Support (list specific sources on following page) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Client and Program Service Fees and Other Earned Revenue FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Contributions (Gifts from Individuals) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Revenue (list specific sources on following page including any endowment income) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL PROJECT/PROGRAM REVENUE$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????PROJECT/PROGRAM EXPENSESSalaries (provide detail by position on a separate page, except for United Way applications)$ FORMTEXT ?????Benefits/Taxes FORMTEXT ?????Professional Fees (itemize on following page) FORMTEXT ?????Supplies, Printing, Duplicating FORMTEXT ?????Travel FORMTEXT ?????Telephone FORMTEXT ?????Occupancy FORMTEXT ?????Payments to Affiliates FORMTEXT ?????Program/Project specific major property & equipment Acquisition FORMTEXT ?????In-kind Expenses (itemize on following page) FORMTEXT ?????Other Expenses (itemize on following page) FORMTEXT ?????TOTAL PROJECT/PROGRAM EXPENSES$ FORMTEXT ?????(Please note: revenue and expenses should add up to total project revenue and expenses.)PROJECT/PROGRAM REVENUE SUPPLEMENT(Please indicate revenue sources as committed or pending)Use additional sheet if necessaryContracts (list)Total RevenueCommittedPending FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Grants (list) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????In-Kind Support (list) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other (list) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PROJECT/PROGRAM EXPENSES SUPPLEMENTUse additional sheet if necessarySalaries (Detail by position)In-Kind Expenses (list) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Professional Fees (list)Other Expenses (list) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Glossary of TermsCapital Request – A planned undertaking to purchase, build or renovate space or building or to acquire equipment. Community – The people living in the same district, city, state, etc.Contribution – A tax-deductible gift, cash, property, equipment or services from an individual to a non-profit organization. Most often given annually.General Operating Support – Funds, both contributions and grants, which support the ongoing services of the organization.Grants – Generally an allocation from foundations, corporations, or government for special projects or general operating. May be multi-year or annual.Indicator – The observable, measurable characteristic or change that represents achievement of the outcome.In-Kind Support – A contribution of equipment/materials, time, and or services that the donor has placed a monetary value on for tax purposes.Methodology – A sequence of activities needed to accomplish the program objectives.Outcomes – The changes in (or benefits achieved by) clients due to their participation in program activities. This may include changes to participants’ knowledge, skills, values, behavior, or condition of status.Performance Standard – The number and percent of clients who are expected to achieve the result. Also called target, they should be based on professional judgment, past data, research, or professional standards.Program – An organized set of services designed to achieve specific outcomes for a specified population that will continue beyond the grant period.Project – A planned undertaking or organized set of services designed to achieve specific outcomes that begins and ends within the grant period. (A successful project may become an ongoing program.)Success Story – An example that illustrates your program’s effect on a client. ................
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