Please note, you can use “Save and Continue” at the bottom to come back to your application later. However, you will have to reattach any documents.

Washington County Healthy Living Fund Grant Application

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This field is for validation purposes and should be left unchanged.

These initial 7 questions will help determine whether your organization and proposal are eligible for the Washington County Healthy Living Grant. The application questions will not open if answered incorrectly.

1. Are you applying on behalf of a 501(c)(3) nonprofit, a tax-exempt organization, a BCF Affiliate, or a BCF Component Fund?(Required)

YES

NO

2. Does your project serve Washington County?(Required)

YES

NO

3. Has your project started more than 1 month ago?(Required)

YES

NO

4. Will your project be complete within 1 year of receiving BCF grant funding? (Fall grant awards are paid in December.)(Required)

YES

NO

5. Is your project related to mental and/or physical wellness?(Required)

YES

NO

6. Is your project for operating support or program support?(Required)

operating support

program support

7. Are you requesting more than 50% of the total cost of your project?(Required)

YES

NO

YOUR ORGANIZATION

Organization Name:(Required)

Organization Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Organization Website:

Tax ID Number(Required)

Nine-digit number issued by the IRS. If you are applying on behalf of a component fund of the BCF, please type the BCF's tax ID number which is 731575838.

Organization Contact (person responsible for grant application):(Required)

Contact Phone Number:(Required)

Contact Email:(Required)

Enter Email Confirm Email

W-9(Required)

Accepted file types: pdf, Max. file size: 16 MB.

If you are applying on behalf of a component fund of the BCF, please upload a blank form.

Solicitor Certificate of Registration from the OK Secretary of State(Required)

Accepted file types: pdf, Max. file size: 16 MB.

This should be your most recent filing to show your organization is registered as a solicitor in the state of Oklahoma. If you are applying on behalf of a BCF component fund, or are exempt from this requirement in the state of Oklahoma, please provide your exemption letter or upload a document with "exempt" typed in text.

First Page of Most Recent 990:(Required)

Accepted file types: pdf, Max. file size: 16 MB.

The first page of your 990 includes your organization's name, filing year, tax-exempt status, and Part 1 and 2 (items 1-22). If you are applying on behalf of a component fund of the BCF, or are exempt from this requirement, please upload a blank form.

Project/Program Name(Required)

Project Budget

Itemized Project Expenses(Required)

Item:

Expected Cost:

 

Add Remove

Be as specific as possible, and use the "+" to add more lines. Your "Expected Costs" should add up to the total cost of your project.

Total Project Cost:(Required)

This should be the total of the costs listed above.

Grant Amount Being Requested:(Required)

Please enter a number from 0 to 10000.

Ideally, this should be the cost of one (or more) of the items listed above. Remember, the amount of the request cannot exceed $10,000.

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Date When Funds Will Be Needed:(Required)

Month

Day

Year

Anticipated Project Start Date(Required)

Month

Day

Year

Keep in mind that awardees are paid in December.

How Will These Grant Dollars Be Used?(Required)

Your explanation should include the specific expense item or items for which the grant dollars would be used as listed above.

Anticipated Funding from Other Sources(Required)

Source

Amount

 

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Be as specific as possible, and use the "+" to add more lines. "Grant Amount Being Requested" + "Anticipated Funding from Other Sources" = "Total Project Cost"

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How many individuals do you anticipate will benefit from this project?(Required)

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Please list any other organizations in this area who are involved in the same or similar project.(Required)

Add Remove

Use the "+" to add more lines.

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Please provide a narrative about the project and the benefits expected.(Required)

NARRATIVE

Please tell us about your proposal by answering the following questions. Each answer is limited to 1500 characters.

1. Provide a brief description of your organization and its mission.(Required)

2. Describe the need for your project, including how the need was determined.(Required)

3. Describe the target population of your project and the expected numbers to be served.(Required)

4. Describe your project and how it serves Bartlesville.(Required)

5. Describe the expected benefits of the project.(Required)

6. Describe your expected outcomes.(Required)

7. Describe your project timeline and process for implementation.(Required)

8. How will you evaluate and measure the success of your project?(Required)

9. How will you sustain this project in the future?(Required)

10. List any other organizations in this area who are involved in the same or similar project.(Required)

11. Describe how your organization is uniquely qualified to deliver this project and how you are collaborating with other organizations.(Required)

Supplemental Attachment: Graphics, such as photos and charts, are e ncouraged to illustrate data and help reviewers visualize your project or product. Upload in pdf format.

Accepted file types: pdf, Max. file size: 16 MB.

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(PLEASE NOTE: When you choose "Save and Continue Later", you will be taken to this grant's home page. You will then need to scroll to the bottom and enter your email address.)

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