Online Grant Application

Due Date for Application is April 30. After this date form will not be accepted!

    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, 2020 must be expended by June 30, 2021.

    If you need additional room, please attach using the "attach additional documents" field below and submit it with your application, attachment size limit is 10 megabytes.

    I. IDENTIFICATION

    1. Agency/ Program Title (required field):

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

    3. Contact phone number (required field):

    4. Additional contact number (if applicable):

    5. Fax (if applicable):

    6. Contact Email:

    7. Site Mailing Address (required field):

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

    Mailing Address, if different than site address:

    9. When did your agency begin providing services?

    10. If the program has received funds under a different name, please list previous name:

    11. Is this program registered with WV Secretary of State? YesNo

    12. Tax ID Number:

    13. Attach a copy of most recent 990. If none filed, explain why:

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

    1. What type of program are you requesting funds for? PantryBackpackMeals

    2. What area of Monongalia County do you serve?

    3. Are services provided at agency site? YesNo

    4. Are all services, including site, ADA accessible? If no, please explain:YesNo

    5. Are services delivered? YesNo

    6. Is there a fee for delivery? If yes, please explain: YesNo

    7. How will you use funds awarded by Empty Bowls Monongalia? Please be specific:

    8. If you received funds from Empty Bowls Monongalia last year, how many units were provided with funds received from EBM?
    For example; Each backpack = 1 Unit, Each pantry visit = 1 Unit, Each meal provided = 1 Unit:

    BACKPACK PROGRAMS

    A. What school(s) are served by your program?
    B. What grade(s) are served by your program?
    C. Total number of individual children participating in your program last year?
    D. Total of backpacks provided last year?
    E. Have you seen an increase or decrease in backpack program participation, explain:

    PANTRY PROGRAMS

    A. Which best describes your programs? Restricted to agency clients or organizational membersRestricted to faith organization affiliationOpen to the community
    B. Do you require identification, financial documentation, or other types of documentation to access your program?
    C. Is there a fee associated with your pantry program? If yes, please explain: YesNo
    D. How many households received food from your pantry during the past year?
    E. How many individuals were fed (to your best data) by food received from your pantry in the past year? (This number should include ALL
    members of the households receiving pantry food supplies):
    F. Provide total number of people served in the categories below:

    Infants (2 and Under):
    Children (3-17):
    Adults (18-55):
    Seniors (55+):
    Individuals experiencing homelessness:
    Individuals with special dietary needs (diabetic, low sodium, low cholesterol, etc.):

    G. Have you experienced an increase or decrease in pantry program participants, explain:

    MEAL PROGRAMS

    A. Which best describes your programs? Restricted to agency clients or organizational membersRestricted to faith organization affiliationOpen to the community
    B. Do you require identification, financial documentation, or other types of documentation to access your program?
    C. Is there a fee associated with your meal program? If yes, please explain: YesNo
    D. How often are meals provided? Mon-Fri, DailyWeekends (Sat and Sun)Once a week
    E. Which of the following populations are served:

    Breakfast
    Infants (2 and Under):
    Children (3-17):
    Adults (18-55):
    Seniors (55+):
    Individuals experiencing homelessness:
    Individuals with special dietary needs (diabetic, low sodium, low cholesterol, etc.):
    Lunch
    Infants (2 and Under):
    Children (3-17):
    Adults (18-55):
    Seniors (55+):
    Individuals experiencing homelessness:
    Individuals with special dietary needs (diabetic, low sodium, low cholesterol, etc.):
    Dinner
    Infants (2 and Under):
    Children (3-17):
    Adults (18-55):
    Seniors (55+):
    Individuals experiencing homelessness:
    Individuals with special dietary needs (diabetic, low sodium, low cholesterol, etc.):

    F. Have you experienced an increase or decrease in feeding program participants, explain:

    III. Financial Report

    1. What year did you first receive EBM funds? (Leave blank if this is your first year receiving):

    2. If funds were received from EBM last year, what was the amount? Attach a report of 2019-2020 food expenditures to this application please.

    3. What is your total 2021 FOOD ONLY budget for the program you are requesting funds for?

    4. What is the amount of funds being requested for this program application?

    5. Excluding Empty Bowls Monongalia, list all sources and amounts of funds anticipated annually received for this program:
    A. United Way:
    B. State Grants:
    C. Federal Grants:
    D. Faith-Based:
    E. Corporate and Business:
    F. Foundations:
    G. Fundraising (Including public donations):
    H. Other: Specify:

    ALL APPLICANTS — Additional Information

    1. Are you interested in receiving food or hygiene donation which may be made to the Empty Bowls office? YesNo
    A. If yes, do you have a method to pick up donations? YesNo
    Please provide a contact name and number:
    B. If interested in receiving food or hygiene donations, what type of items are most beneficial for your program?

    2. If you have received Empty Bowls Monongalia funding in the past, please tell us for EBM funds have impacted your program.If possible, please share a story and/or specific comments about how funding has affected your clients. (for privacy reasons, no names of individuals please)

    3. Please provide any additional information or comments you feel will support your request for an Empty Bowls Monongalia grant for the 2020 application.

    4. Does your organization/agency engage in regular financial reviews, please explain:

    5. Has your organization/agency developed a succession plan, please explain:

    6. Please check to ensure all additional requested documents are attached.
    Recent 9902019-2020 Food Expenditures

    To attach any additional documents please you the option below.

    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