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CITY OF CODY COMMUNITY FUNDING PROGRAM APPLICATION (Type or print clearly, form is available in electronic format) APPLICATION DEADLINE – MARCH 22, 2013 5PM Today’s Date: Organization Requesting Funding Name: Address: Phone Fax Date Organized: Total Annual Budget: Organization Contact Person(s) 1. Main Contact Person and Title: Phone No: Email: 2. Secondary Contact Person and Title: Phone No: Email: Organization Board Members (if applicable) Name: Office: Name: Office: Name: Office: Name: Office: Name: Office: Name: Office: Name: Office: 2013-2014 Funding Amount Requested Purpose Amount Necessary support of the poor $ Economic or Industrial Development $ Promoting/advertising the resources of the City $ Providing services to the citizens of Cody $ Encouraging exhibits at fairs, expositions and conventions $ Other (explain): $ Total Requested Amount $ 1 0.00 ---PAGE BREAK--- Section I: General Information 1. What is the organization’s mission? 2. Where are the organization’s headquarters located and what geographic area do the organization’s programs/services cover? 3. What demographics are being served by the organization and what is the population number in Cody that will be served? 2 ---PAGE BREAK--- 4. What programs are currently offered by the organization and how would entering into a contract-for-services relationship with the City of Cody directly benefit Cody citizens? 5. In addition to the programs/services the organizations is requesting funding for what new or different programs/services does the organization anticipate for the upcoming year and how will they be financed? 6. Does the organization provide the same or similar services which are already being provided by other organizations (profit or non-profit) in the City. If so, please explain. 3 ---PAGE BREAK--- Section II: Funding Request Detail 1. Describe how the organization’s prior year funding was used and what impact receiving this funding had on the organization. If it was not used for its original intent, please explain why. If this is the organization’s first request for funding please enter N/A below. 2. Using the table below and in narrative form explain specifically how this request from the City will be used for specific programs or events? If any of this funding will be used for a grant match describe the grant and associated matching requirements. Indicate other sources and amounts of funding for the programs/services listed. Purpose – Specific Program or Service Amount of City Funding Requested Amount of Requesting Organization’s Funding Amount of Other Local Gov’t Funding Amount of Grant Funding Amount of Funding from Other Sources Explanation: 4 ---PAGE BREAK--- 3. How much of the funding requested will be used for the following expenses: Amount Salaries & Benefits $ Travel Expenses $ Materials & Supplies $ Utilities & Fuel $ Professional & Contract Services $ Advertising & Promotion $ Capital Outlay $ Other (explain): $ 4. If the current total funding request is more than the previous year’s award, please explain why. 5. How will the organization’s programs/services be affected if the requested funding is not received? 5 ---PAGE BREAK--- Section III: Budget and Administration 1. Please answer the following questions: 1a Is your organization incorporated as a non-profit organization under Wyoming State Law? Yes No 1b Is your organization tax exempt under the Internal Revenue Service? If yes, under what section Yes No 1c Do the minutes of your board meetings reflect authorization for the proper disbursement of funds? If no, please explain: Yes No 1d Does your organization have a clear policy governing the approval of expenses? If no, please explain: Yes No 1e Has your organization adopted a policy of non-discrimination in all levels of operation? Yes No 1f Does your organization operate on an approved budget? If no, please explain: Yes No 1g Has your organization operated within its budget for the past four years? If no, please explain: Yes No 1h Does an independent public accountant review the accounts and expenditures of your organization? Yes No 1i Does your organization have a policy regarding cash reserves or fund balance for your organization? Yes No 1j What plans have been made to financially sustain the organization over the long term? How is the organization prepared for an unexpected loss of revenue? Please explain below: 6 ---PAGE BREAK--- ASSETS 2012 Actual 2013 Projected Cash/Cash Equivalents Short-Term Investments Accounts Receivable Inventory Prepaid Expenses Other Current Assets Machinery & Equipment Furniture & Fixtures Leasehold Improvements Land & Buildings Other Fixed Assets Accumulated Depreciation Intangibles Goodwill Deposits Other TOTAL ASSETS LIABILITIES 2012 Actual 2013 Projected Accounts Payable Interest Payable Short-Term Notes Current Portion of Long-Term Debt Accrued Expenses Other Current Liabilities Bank Loans Payable Notes Payable Other Long-Term Debts TOTAL LIABILITIES EQUITY 2012 Actual 2013 Projected Restricted Retained Earnings/Fund Balance Unrestricted Retained Earnings/Fund Balance TOTAL EQUITY TOTAL LIABILITIES & EQUITY 2. BALANCE SHEET You may attach a computer-generated balance sheet from your accounting system sheet in lieu of completing this form. 7 ---PAGE BREAK--- INCOME 2012 Actual 2013 Projected Fundraising Income Federal Grant Income State Grant Income Local Grant Income City of Cody Funding Donations/Contributions Income Program/Participant Income Sales Income Investment Income Realized & Unrealized Gain on Investments Other Income: TOTAL INCOME EXPENSES 2012 Actual 2013 Projected Wages & Benefits Travel & Training Materials & Supplies Professional & Legal Services Advertising & Marketing Maintenance & Repairs Insurance Utilities & Telephone Interest on Debt Other Expenses: TOTAL EXPENSES NET INCOME CAPITAL OUTLAY 2012 Actual 2013 Projected Machinery & Equipment Furniture & Fixtures Leasehold Improvements Land & Buildings Other Capital Outlay: TOTAL CAPITAL OUTLAY 3. INCOME STATEMENT You may attach a computer-generated income statement from your accounting system in lieu of completing this form. 8 ---PAGE BREAK--- 4. Please identify the amounts and purpose of all cash/cash equivalents and cash reserves being held by the organization. Operating: DESCRIPTION AMOUNT IF RESTRICTED, EXPLAIN WHY Capital: DESCRIPTION AMOUNT IF RESTRICTED, EXPLAIN WHY Authorization I declare and affirm under penalty of perjury that the statements and information presented herein are true and correct to the best of my knowledge, information and belief and I that I am authorized to make this application on behalf of the Organization identified on this application. Authorized Signature Title Date 9 ---PAGE BREAK--- CITY OF CODY COMMUNITY FUNDING PROGRAM POLICY I. Intent and Criteria of the Community Funding Program 1. Funding requests must satisfy the following minimum criteria and be used for the purposes described below to be considered: a. The funding must be used for a public benefit b. Adequate consideration must be exchanged c. Authority must exist pursuant to the Wyoming Constitution Article 16, Section 6, and Wyoming Statutes 15-1-103; 15-1-111 or 15-1-701. Specifically, the funds shall be used for the following: 1. Further industrial and economic development in the City of Cody 2. Provide necessary support of the poor 3. Promote services and programs that provide a direct benefit to the citizens of Cody 4. Advertising the resources of the City 5. Encouraging exhibits at fairs, expositions and conventions II. Funding Availability 1. Requests for funding may be awarded as cash or in-kind staffing and services provided. 2. Funding requests will be for the actual expenses associated with a specific program, event or capital purchase. No funding shall be provided for the following: • Any private citizen, firm or corporation, or other for-profit entity • General operational expenses not directly related to a specific program or event • Salaries not directly related to a specific program or event • Re-distribution as an award, contribution or financial support to other organizations or individuals 3. Funding is not guaranteed. The Governing Body reserves the right to deny funding to any applicant for any reason including but not limited to the following: • The request does not meet the intent of the Community Funding Program • Funding the request would be a violation of any Federal, State or local law • The applicant is a private individual or for-profit enterprise • The applicant does not establish a funding need • The applicant primarily serves citizens who reside outside the Cody area • The applicant’s audit report reflects internal management problems • The applicant is requesting funding for programs or events which are outside the scope of traditionally sponsored governmental programs • Funds are not allocated in the budget • The application is received late, is incomplete or is found to contain false information. 4. Approved requests shall be funded from sources designated by Resolution of the City Council. 10 ---PAGE BREAK--- III. Award Process 1. In order to be considered, applications must be received by the due date indicated on the application form. Late and incomplete applications will not be accepted or considered. 2. Once the applications have been processed by staff, the City Council will meet to discuss the applications. Select applicants may be invited to address the Council to clarify their applications and answer questions. 3. Council will conduct a public meeting to determine which applications will receive consideration during the budget process. Those applications that are not supported by the majority of the Council will not be given further consideration for funding during the proposed fiscal year. 4. Organizations whose applications that are not selected for further consideration will be notified in writing. 5. Organizations whose applications are funded will be required to enter into a contract with the City of Cody for providing the services/programs approved. IV. Payments under the Contract 1. Funding is payable on a reimbursable basis. In order to receive funds, approved organizations shall be required to submit a reimbursement request on a form provided by the City. 2. Supporting documentation, such as receipts, invoices, detail ledger reports and other records which may be requested by the City must be attached to the reimbursement request and shall be reviewed by the City prior to processing. If the reimbursement request is for advertising, attach a copy of the affidavit of publication. 3. Reimbursement checks will generally be issued within 45 days of receipt of the request. 4. The City reserves the right to deny any reimbursement requests for expenses outside of the scope of the contract for services. 5. Funds awarded are for one Fiscal Year and any funds which are unused as of June 30th will revert back to the City. Unused funds cannot be carried over into the next year. V. Mid-Year Requests 1. The City Council may choose to accept funding requests which are received outside the budgeting process if: a. Funding is available AND b. Requests meet the intent and policy of the Community Funding Program 2. The Council may also consider emergency funding requests that cannot wait until the normal funding process timeline. 11 ---PAGE BREAK--- APPLICATION INSTRUCTIONS 1. The application must be: • Typed or printed legibly (electronic version is available) • Completed in its entirety Please be sure all numbers are added correctly and balance and all questions have been answered. • Include all required attachments (see Please do not include any additional paperwork unless requested. • Be submitted by the due date specified on the application Late and incomplete applications will not be accepted or considered. 2. Required Attachments • Copy of the organization’s most recent balance sheet, income statement and audit report including a copy of any management letter that may have been issued (if applicable). • Copy of the organization’s State of Wyoming or IRS documentation of non-profit status. 3. Number of application and required attachment copies required: TWELVE (12) PLEASE SUBMIT THE REQUESTED NUMBER OF COPIES THREE- HOLE PUNCHED WITH NO STAPLES, BINDINGS, OR COVERS. Submit twelve (12) copies of the completed application and required attachments by the deadline to: City of Cody ATTN: Finance Officer 1338 Rumsey Avenue P.O. Box 2200 Cody, WY 82414 [PHONE REDACTED] 12