Grant Application Form | Stuller Family Foundation

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A Grant

Program Grant Application

In addition to the application form please submit:

A DETAILED PROGRAM BUDGET FOR THE PROGRAM IN WHICH YOU ARE REQUESTING FUNDS
A detailed operating budget
For those with fiscal sponsors please provide a fiscal agent’s letter or agreement
Supplemental documents – not required but if submitted should be limited to essential materials only

For questions, please get in touch with stullerfoundation@stuller.com or (337) 262-7713.

"*" indicates required fields

Step 1 of 2

50%

Organizational Information

Legal Name of Organization Applying*

Website/Social Media Link

Year of Formation*

Employee Identification Number (EIN)*

Address*

City / State / Zip Code*

Organization Mission*

Limit to 100 words or less.

Organization Classification*

No. of Full Time Employees*

No. of Part Time Employees*

Other Classification

Organizational Funding Sources

100% Total - Sources should add up to 100%. Round to the nearest whole percentage

The total percentage cannot exceed 100%. Please adjust your input.

% Federal Grants*

% State Grants*

% Local Grants*

% Donations*

% Membership Dues*

% Program Fees*

% Service Contracts*

Total Annual Revenue*

Total Annual Expenses*

Revenue Less Expenses

Please provide explanation

Total Assets*

Total Liabilities*

Net Assets of Fund Balances

Please provide explanation

Annual Functional Expenses

Total Salaries*

Total Program Expenses (w/o salaries)*

Total Program Expenses

Operational Transparency

Board Compensation*

Yes

No

Independently Audited Financials*

Yes

No

Loans to Disqualified Persons*

Yes

No

Material Diversion of Assets*

Yes

No

Documented Board Minutes*

Yes

No

Whistleblower Policy*

Yes

No

Conflict of Interest Policy*

Yes

No

Loans to Disqualified Persons - Please provide explanation

Material Diversion of Assets - Please provide explanation

List All Board Members

Name

Board Title

Company/Organization Associated (if applicable)

Grant Request Information

Total Amount Requested*

Total Program Cost*

Requested as a Match*

Yes

No

Geographic Area Impacted by Grant*

Acadia Parish

Lafayette Parish

St. Landry Parish

St. Martin Parish

Vermilion Parish

Iberia Parish

State of Louisiana

Other (please specify)

Other Area (please specify)

Area Impacted by Grant*

Brief description of grant request*

Please attach a detailed budget related to the program or request for which you are applying

How will you measure the success/impact of this grant request?*

Major Sources of Funding In Support of This Request

Sources should represent 80% of the total program cost. You may include this grant request as a source for the calculation.

The total percentage cannot exceed 100%. Please adjust your input.

Total Funding Received to date in support of this program*

1) Source Name

Amount 1

Source 1 Selected

Requested

Received

2) Source Name

Amount 2

Source 2 Selected

Requested

Received

3) Source Name

Amount 3

Source 3 Selected

Requested

Received

4) Source Name

Amount 4

Source 4 Selected

Requested

Received

File Upload*

Required Documents
- Copy of a program budget
- Copy of an operational budget (only for those organizations who file a 990-N/e-postcard, or religious institution) all other supporting documents

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

How did you hear about the Stuller Family Foundation?*

Previous Applicant/Grant Recipient

Stuller Family Foundation website

LinkedIn

Facebook

Grant Watch

Stuller Family Foundation Sponsored Event

Parish Proud Event

Stuller Inc. Employee

Community Foundation of Acadiana

Referred by another organization (please specify organization)

Referred by an individual (please specify individual)

Other (please specify)

Please Specify Organization

Please Specify Individual

Other (please specify)

Primary Grant Contact Name*

Phone*

Email*

Executive Director Name*

Phone*

Email*

Submission Authorization*

By checking this box, the individual submitting this application is duly authorized to do so. Where applicable, program staff, leadership and/or board members whose work will be impacted by this grant, if awarded, are aware of this grant application. Acceptance of a donation from the Stuller Family Foundation is an agreement to use the grant as designated in this application form. The Stuller Family Foundation reserves the right to withhold or stop funding if the organization’s charitable purpose or the use of this specific grant is not as indicated herein. Completion and/or submission of an application is not an agreement to fund and does not constitute any liability for, or to, The Stuller Family Foundation to furnish or provide any financial support or backing to the applying organization.

Applicant Name*

Signature*

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Contact Us

(Required)

First Name Last Name

Phone

Email

Message

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Contact

P.O. Box 82277 Lafayette, LA 70598
(337) 270-2143
Fax (337) 262-7713

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