Project Grant Application EmailThis field is for validation purposes and should be left unchanged.Please note: ALL items and fields are REQUIRED and must be completed!1. State applicant organization typeLocal Chapter/Association/OtherHemophilia Treatment CenterNational Organization 2. Contact Information In the event that the staff who submitted the grant request leaves the organization during the grant period, the Foundation needs the contact information for a second individual who is responsible for the project.a. Name of applicant organizationb. Address of organization Street Address Address Line 2 City State / Province / Region ZIP / Postal Code c. Address to send check if that differs from the organization’s address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code d. Name of primary contact persone. Telephone of primary contact personf. Email of primary contact person g. Name of secondary contact personh. Telephone of secondary contact personi. Email of secondary contact person 3. Is this a collaborative grant with another/other eligible organization(s) as defined in the grant guidance? Yes No Please list name(s) of collaborating organization(s) in the space provided below 4. Amount Requested: $8000 maximum for local Chapters, Associations, and Hemophilia Treatment Centers; $10,000 maximum for national organizations. Note: If both a project grant and a patient assistance grant are being submitted, please carefully read the Grant Guidance for maximum amounts that can be requested.a. Total Amount Requested for Grant.b. If this is a collaboration grant, list collaborating organizations and how much is requested for each.5a. Name of authorized Individual5b. Signature of authorized Individual6. Organization description: brief description of mission, geographic service area, and # patients or families served. If this is a collaboration grant, describe briefly for each organization. 10 points7. Brief description of the need that the project addresses. 10 points8. Overall description of the project including the various activities that the project will include with a specific time-line for these activities. 10 Points9. Concisely state the specific project goals and measurable objectives. THESE MUST BE STATED AS SMART OBJECTIVES: Specific, Measurable, Achievable, Relevant, and Time-bound with a concise timeline for meeting the project's objectives. Refer to Grant Guidance for suggestions how to write SMART objectives. 10 Points10. How will you measure/evaluate the success of the project? Data collection methods should be specific and align with the proposed activities of the project. Who will manage/monitor the evaluation process? 10 Points11. How will the project strengthen your organization and improve the lives and care of persons/families with bleeding disorders? 10 Points 12. Budget and Budget Narrative 10 Points Budget: must be itemized with each item and amount including personnel. For collaboration grant, include all collaborators and their relevant allocation of funds. NOTE: Personnel expenses up to but not exceeding 25% of the total grant request and incurred exclusively for the grant project activities will be considered. See budget and budget narrative in Grant Guidance. Click on (+) to add more rows if needed.Description$ Amount Add RemoveTotal Amount RequestedBudget Narrative: Clearly justify all budget line items. Include an explanation of personnel, their name, role on the project, and salary/hourly charge. Include all equipment, travel, supplies, and other expenses with details. NOTE: Personnel expenses up to but not exceeding 25% of the total grant request and incurred exclusively for the grant project activities will be considered. Be sure to include required attachments specified in the Guidance. Note: your uploaded documents MUST be in PDF, JPG, or JPEG format. THE APPLICATION MUST BE SUBMITTED ONLINE. ONCE COMPLETED, THE REPORT MUST BE SUBMITTED ELECTRONICALLY BY PRESSING THE “SUBMIT” BUTTON AT THE BOTTOM OF THIS FORM. YOU WILL RECEIVE AN ELECTRONIC CONFIRMATION OF RECEIPT.Acknowledgement(Required) The grant applicant acknowledges and agrees to comply with all applicable state and federal laws including but not limited to the Federal Anti-Kickback Statues as found in Section 1128 D(b) of the Social Security Act and 42 U.S.C. Section 1330a-7b(b). Note 1: After clicking the “Submit” button below, a notification email will be sent to the Primary Contact Person’s email address that includes a copy of your report in PDF format. The PDF will be attached to the email. Note 2: If, after submitting the form, you don’t receive a notification email in your Inbox, then please check your spam folder and whitelist the email address info@hemophiliaalliancefoundation.org. YOU ARE RESPONSIBLE FOR MAKING SURE YOU RECEIVE THIS ACKNOWLEDGEMENT OF RECEIPT.Copy of your IRS Determination Letter or 501(c)(3). If collaboration grant, submit for each organization. Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB. Copy of your organization’s W-9. For collaboration grant, only submitting organization needs to include their W-9. Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB. Letters from collaborating entities (required if collaboration grant) Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB. Letters of support (optional) for entities critical to the project for which grant funding is not being requested Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB.
