MEMORANDUM

 TO:               Madison County Mental Health Board
                       New Applicants for Funding 

FROM:          Jennifer Roth, Executive Director                       

DATE:            July 1, 2016 

RE:                 Funding Application Materials for FY 2017 

In the links below you will find the materials needed to complete the FY 2017 funding application for all new agencies.  In completing the application materials, please keep in mind the following: 

• Thoroughly complete all forms, being as descriptive as possible (a checklist has been attached for your assistance); 

• Be sure to identify a profile of individuals benefiting from local funding and clearly name service outcomes.  If available, include any local statistics/data pertinent to the needs of the populations you are serving. Attach any supplemental materials you wish; and 

• Please include one total copy of your Form 990 

Please note - materials in this application package cannot be saved online.  Save the files to your computer.  Due to formatting issues of prior years, we are using Microsoft Word documents.   

We want to make the application process as smooth as possible for everyone.  If you find it necessary to make some additions/minor adjustments to the documents, such as adding lines to the financial forms - that is acceptable.  We ask that you not completely reformat the documents or make any extreme content changes. 

The Board cannot assure that all requests will be funded.  We will be reviewing funding priorities to ensure core services can be continued. Application review meetings may be utilized as necessary by Board and Staff.  Feel free to call the office to further discuss your submitted application or if you have any questions about the forms or process at 618-296-4358.  

Applications are due by 12:00 p.m. on Wednesday, July 27, 2016 (received in office – not postmarked).  Kindly return ten (10) completed copies of your application to the Board office.  Each of the ten copies should include a cover letter and all application forms for Board and Staff review.  

Thank you.

1.   Checklist for New Applicants
2.   Request Page
3.   Directions for New Applicants
4.   Cover Page
5.   Expense & Revenue Forms
6.   Personal Listing Page
7.   Board Member Listing Pages 
8.   Service Plan Pages
9.   General Agency Information page
10. Poverty Guidelines Table