Online Grant Application

Due Date for Application is March 31st after this date this form will not be available.

Application Form

If you receive an Empty Bowls Monongalia award, you will need to supply receipts for food purchased, when requested.

All funds from Empty Bowls Monongalia must be used to purchase food.

Funds awarded by June 30, 2017 must be expended by June 30, 2018.

If you need additional room, please attach a separate sheet of paper and submit it with your application, attachment size limit is 10 megabytes.

IDENTIFICATION

I. Program/Site Applicant Name (required field):

II. Name of Individual Submitting Application (required field):

III. Title of Individual Submitting Application:

IV. Site Mailing Address (required field):

V. Is your mailing address different than site address? YesNo

Mailing Address, if different than site address:

VI. Home/Mobile Phone (required field):

VII. Site Phone (required field):

VIII. Email address of person submitting application (required field):

GENERAL INFORMATION (The information requested in this section refers specifically to the program for which you are requesting funding from Empty Bowls Monongalia)

1. Is your program a Weekend Backpack Food Program (required field)? YesNo

2. Is your program a Food Pantry (required field)? YesNo

3. Is your program a Meal Program (required field)? YesNo

4. Is your food pantry or meal program handicapped accessible? (required field) YesNo

If no, what accommodation(s) do you make?

5. Is your program under the umbrella of a faith-based organization? (required field)
YesNo

If yes, please specify:

6. What is your Tax ID number (required field)?

7. Is your program a 501(c)3 organization? (not required for funding) YesNo

8. Is your program registered with WV Secretary of State? (not required for funding) YesNo

9. Are you required to file a 990? (not required for funding) YesNo

If yes, please include a copy of your 990 with this application.

10. What was your total 2016 budget for food only for the program for which you are making this grant application (required field)?

11. Aside from Empty Bowls Monongalia, for the program for which you are making this grant application, what sources of funding do you receive? (required field) (i.e. United Way, public donations, government grants, business donations, faith-based organizations, foundations, etc.)

12. Have you seen a change in the average number of monthly recipients in your program over the past year? Please and give examples, if possible.

13. What is your funding request from Empty Bowls Monongalia this year (required field)?

14. How will you use any funds awarded by Empty Bowls Monongalia? Please be specific.

15. Does your organization have an approved accounting system? YesNo

16. What area of Monongalia County do you serve? (required field) (please explain, such as western, northern, southern, eastern, Morgantown, all of the county, etc.)

17. Has your organization changed name/title in the past? YesNo

If yes, did your organization receive funding from Empty Bowls Monongalia under the previous title? YesNo

If yes, please provide the prior organization name/title receiving funding from Empty Bowls Monongalia.

FOOD PANTRY applicants answer the following 3 questions

1. How many individuals are fed by your food pantry during an average month?

2. How often is your pantry open to dispense food? Please provide your weekly/ monthly schedule for providing food to your clients on a separate attached sheet.

3. Do you provide food for the following? (Check all that apply & list numbers served)
InfantsChildrenAdultsElderlyHomeless IndividualsIndividuals with special dietary needs
Infants Served:
Children Served:
Adults Served:
Elderly Served:
Homeless Individuals Served:
Individuals with Special Dietary Needs Served:

MEAL PROGRAM applicants answer the following 3 questions

1. How often do you provide meals?
7 days/week5 days/weekWeekends only (Sat. & Sun.)Sundays only
If other please specify:

2. How many meals do you provide on an annual basis? Check all that apply and list numbers served beside meal.
Breakfast
Lunch
Dinner/Supper      
School/Work lunches for carry out      

3. Do you provide food for the following? Check all that apply.
InfantsChildrenAdultsElderlyHomeless IndividualsIndividuals with special dietary needs

BACKPACK WEEKEND FOOD PROGRAM applicants answer the following question

1. What schools and grades do you serve?

2. List the estimated number of backpacks you provided during the year.

3. Do you have plans to expand this program? YesNo

If yes, please explain.

ALL APPLICANTS — Additional Information

1. Would your organization be willing to sell tickets for our 2018 luncheon? YesNo

2. Do you have a method to pick up food from food donation collections at the Empty Bowls office? (required field) YesNo

If Yes, please provide name and contact information for the individual who could pick up the food:


3. If you have received Empty Bowls Monongalia funding in the past, please tell us about the differences that funding has made to your program. If possible, please share a story and/or specific comments (on a separate sheet of paper) about how funding has affected your clients. (for privacy reasons, no names of individuals please)

4. Please provide any additional information or comments you feel will support your request for an Empty Bowls Monongalia grant for 2017-2018 on a separate sheet of paper and include it with your application.

5. If your organization has a mission statement and would like it featured on our website if your application is chosen, please include a copy with your application.

6. Please include our organization on your distribution list for newsletters and annual report and any other material, such as a copy of your board of directors and their appointment process, that may be of relevance. You can send this material by mail or submit it via email.

7. To attach any additional documents please you the option below.

8. If you have questions regarding the application, please contact one of the agency liaison committee members below.
Nel Kimble - Email: nelkimble@yahoo.com or Cell: 304-767-1676
Travis Mollohan - Email: mollohan.travis@gmail.com or Cell: 304-951-7197