Emergency Assistance Fund Application

Area foundations and funders are working to coordinate efforts to respond to grant requests from Central Texas nonprofit agencies who are providing basic needs services to individuals and families hardest hit by the economic recession. The Austin Community Foundation (“ACF”) will receive these applications and share them with other foundations and funders in the Austin area in order to help coordinate the availability of funds. The foundations and funders may respond to this request directly or through the Emergency Assistance fund established at ACF.

Applicants must be either (i) non-profit organizations exempt under Sec. 501(c)(3) of the Internal Revenue Code, or (ii) a governmental entity that does not have emergency relief as its primary purpose (e.g. a public school or public health clinic).

Please explain your best estimate of the TOTAL financial burden your organization has incurred to date, and expects to incur over the next three to six months, relating to emergency assistance for basic needs services. The costs should only include expenses for which your agency has not received or does not expect reimbursement from other sources, including private donations.

Please note that the purpose of these expedited grants is to assist with the short to intermediate term financial burdens caused by the severe economic recession.

If your agency is interested in applying, please complete this form and submit it online or via fax (472.4486) or email to MariBen Ramsey at mbramsey@austincommunityfoundation.org. ACF will acknowledge receipt of your proposal via email. You may expect a response in no more than eight weeks of receipt by ACF. You may be asked to provide financial and other documentation if ACF does not have such information already on file or available.

If you have any questions, please feel free to contact ACF at 472.4483.

*Agency Name

*Contact Person First Name

*Contact Person Last Name

Contact Person Job Title

*Phone Number

*Contact Email

*Address 1

Address 2

*City

*State

*Zip Code

*Agency Website

*FEID Number

Estimate of Costs Not Expected to be Reimbursed from Other Sources

Amount Requested

Total 2009 Agency Budget

What activities or services does your agency provide?

(Please enter your reponse below):

What is the population you are serving (e.g. children, low-income, general population)?

(Please enter your response below):

Describe the increased caseload your agency is experiencing as a result of increased demand for services resulting from the recession. Also describe in terms of a percentage the increase this number of additional persons represents over the number of people you typically serve annually.

(Please enter your response below):

Please describe the basic needs services or program for which you need immediate funding. How many unduplicated clients will be served with the funding and over what time period?

(Please enter your response below):

Please describe any expenditures made, or anticipated to be made, for which your agency does not expect reimbursement from other sources. Please be as specific as possible (contract labor, equipment rental or purchases, etc) in describing these costs.

(Please enter your response below):

By clicking this box I certify on behalf of the Agency that, to the best of our knowledge, we have accurately represented the expenses we have incurred or anticipate incurring which will not be reimbursed.

*Submitted By (Name):

*Job Title: