Kingsburg Healthcare District Grant Application

Please complete and return the documentation and information required under the District Grant Policy, Procedures, and Guidelines. Submit a signed original plus a set of 7 copies using a binder clip. Provide the following information for the grant applicant, as well as for all partnering and/or subcontracting entities, if any.

Individual Accountable for Grant Funds:

By signing below, the undersigned hereby certifies under penalty of perjury that; (1) information contained within this application is true and correct to the best of my personal knowledge, information and reasonable belief; (2) the grant applicant has read and is familiar with all of the District’s grant policies, procedures and guidelines; (3) the grant applicant hereby waives each and all claims and right(s), if any exist to, in any form, appeal or otherwise legally challenge each and all decisions of the Kingsburg Healthcare District about this grant application; and (4) the governing body of the grant applicant has duly authorized me to sign this grant application.

The following information is required in relation to the requested grant. Please use separate pages for each numbered item, titling and numbering each page as listed below. If a numbered item has no short response, you may combine them on one page if they are numbered and titled appropriately. We require one (1) signed copy of the grant application, with pages 1-8 completed and attached, and seven (7) additional copies.

1. Project Overview: Include the purpose of the grant request. Describe in detail how the funds will provide health and wellness services, as well as further the grant goal of fostering quality health services and programs that benefit the residents of the District. 2. Project Cost: Itemized budget with explanation of individual costs and need(s) of such and supporting documentation, such as official bids (which should be for 90 days), if any. 3. Partner(s): List all partners (if any) and their financial contributions for this specific project. 4. Funding Sources: List all funding sources for the past 5 years. 5. Community Need: Describe the specific needs of the district that your project will meet. 6. Legal Status: Please provide a copy of your W-9, business licenses, and certificates, as well as an IRS determination letter if you are a nonprofit. 7. Contributions: List previous and ongoing community contributions your organization has made within the past 5 years. 8. Plans: Provide drawings or pictures of the proposed project with footnotes for explanations.