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Request for Funding

General Guidlines:

The Requester must be a group or individual, in Eastern Idaho, with a funding request for a program/project/event that fits the mission of Breaking Boundaries. Preference is given to groups to maximize the impact of Breaking Boundaries' giving.
Requests are considered monthly by the Board of Directors of Breaking Boundaries or its designees. Submit the online Request for Funding form before the 15th of the month. Requests not received by the 15th may be deferred until the following month. The Requester must promote and provide recognition to Breaking Boundaries.
This form is to request funding of a program/project/event from the Breaking Boundaries “Diversity” Fund. Requests to fund medical care or expenses of those living with HIV/AIDS in Eastern Idaho are considered and funded separately, through the Breaking Boundaries “Care” Fund, and should originate through Case Managers in Public Health District 6 and 7. Call 208.533.3213 to present HIV/AIDS medical care or expense funding requests.

Requesting Organization or Individual*

Primary Contact (if other than above)

Address*

City*

State*

ZIP*

Phone Number*

FAX

Cell (Leave Blank)

Email Address*

Web Site (if applicable)

Is the Requester a duly-approved 501(c)(3) Organization?*

Requester's Mission Statement or Purpose*

Amount Requested ($)*

How will money be used? (Describe the project/program/event the funds would support)*

How has the need for this project/program/event been determined?*

Who will benefit from this request - and how?*

Is this request for All or Part of the project/program/event?*

Requester's budget for this particular project/program/event ($)*

If the total cost of the project/program/event is greater than the amount requested from Breaking Boundaries, submit budget and documentation showing how you plan to accomplish the remainder of your fundraising. Please include amounts and sources of pledges received to date for the project/program/event, and/or other funding sources to which you have applied, together with amounts that have been requested from each. Note that if this Request is funded, Breaking Boundaries expects timely evidence of project/program/event completion, and if the project/program/event is not completed, refund of amounts granted.

Is this a local, statewide, or nationwide project/program/event?*

If statewide or nationwide, please describe the local impact within the region of Eastern Idaho.

Have you sought funding from Breaking Boundaries in the past?*

If yes, when, and for what purpose?

Was your prior request(s) funded by Breacking Boundaries?*

If yes, in what amount? ($)

Is this an annual project/program/event?*

If yes, how will this project/program/event be funded in the future? ($)

Date of project/program/event (if applicable):

What date will communications and marketing for this project/program/event begin?*

If this request is funded, how (specifically) will Breaking Boundaries be acknowledged?*

Requester's total annual operating budget:* ($)

% from private donations*

% from government grants*

% other (please specify)*

Narrative description of how project/program/event promotes the Requester's mission*

Narrative description of how project/program/event supports Breaking Boundaries' mission*

Date funding decision is needed*:

Date funds are needed*:

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* Required Fields

Rev. 1.0 3/01/11