FCSS Grant Application "*" indicates required fields 1Contact Details2Organization Details3Project Details4Project Funding5Attachments6Terms & Conditions President / Chairperson Full Name*President / Chairperson Email* President / Chairperson Phone*Is the contact person for this Grant Application different from the President / Chairperson contact information found above?* Yes No Grant Application Contact InformationFull NamePositionEmail Phone Number Organization Name*Society of Registration No.Date of Registration MM slash DD slash YYYY Organization Mailing Address* Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Organization Mandate*Organization Executive(s)Select (+) to add additional rows, as necessary.Executive NameExecutive PositionExecutive Email Add Remove Project Name*Statement of Need: What community issue, need or situation are you responding to?*Overall Goal: What change or impact do you want to achieve?*Broad Strategy: How will you address the issue, need or situation?*Rationale: What evidence do you have that this strategy will work? Research? (If/then statement)*Target Group: Who is served?*How many Sturgeon County residents will be directly affected by this project?*If the project ran last year, how many Sturgeon County residents were affected by the project?*Please attach any supporting documentation including project promotional materials, organizational information, and/or letters of support with this application. Drop files here or Select files Max. file size: 128 MB. To be accountable to the Provincial FCSS program, Sturgeon County must ensure that all grant funds are expended as approved. Please complete in the anticipated budget amounts below for all funding and costs related to the project. Sturgeon County FCSS Grant Amount Requested (Max. $5000)*How will Sturgeon County be recognized for its funding support?*Is your organization receiving funding from any other municipal or government agency?* Yes No Please specify the agencies below:*Select (+) for each additional agenciesAgency NameFunding Amount Add RemoveIs your organization receiving funding from any other funding sources?* Yes No Other Funding Sources*List all sources of anticipated funding related to the project. Include other government funding, organization contribution, & donated in-kind contributions. Note: The difference between your project funding and project cost must be of equal value. Select (+) to add additional rows.Funding Source DescriptionPending AmountConfirmed Amount Add RemovePlease list all anticipated expenses related to the project.*Note: The difference between your project funding and project cost must be of equal value. Select (+) to add additional rows. Project Expense DescriptionAnticipated Cost Add Remove Please upload a Valid Liability Insurance Certificate along with your organization’s most recent Audited Annual Financial Statements. Liability Insurance Certificate Drop files here or Select files Max. file size: 128 MB. Latest Audited Annual Financial Statements Drop files here or Select files Max. file size: 128 MB. Privacy Policy Consent*The personal information you provide will be used to process the Family & Community Support Services Grant Application and is collected under the authority of section 4(c) of the Protection of Privacy Act (POPA). If you have any questions about the collection or use of this information, please contact the Sturgeon County Access and Privacy Advisor at (780) 939-1306 or accessandprivacy@sturgeoncounty.ca. I agree to the privacy policy above.Terms and Conditions Consent*I hereby certify that I am an authorized signing official of the applying organization, the information provided is complete and accurate, and is endorsed by the organization I represent. I accept and agree to the terms and conditions of the grant program.
