The Evelyn W. Preston Memorial Trust Fund
Bank of America, Trustee
2009 Grant Application
Please read the Guidelines carefully and follow all instructions before completing the form.
The application must be received in the attached form or it will not be accepted. Please see the Grant Guidelines for complete instructions on the due date, correct formatting and number of copies required.
| Applicant Name: Event Name: Amount Requested from Evelyn W Preston Memorial Trust Fund: |
| APPLICANT INFORMATION | |
| Applicant Name (organization): | |
| Applicant Address: | |
| Applicant Mailing Address: | |
| Applicant Telephone: | Website: |
| Email: | Fax: |
| Contact Person: | Title/Function: |
| Telephone: | Email: |
| Fiscal Agent (if necessary): | |
| Fiscal Agent’s Mailing Address: | |
Self-identify your style of music:
Nonprofit Organizations Applicants Only
Please provide a brief history of the organization’ goals and objectives.
| If you are proposing a concert(s) utilizing City of Hartford property or services, please respond to the following questions. |
| Have you ever received a Special Events Permit with the Risk Management Department? |
| □ Yes □ No |
| Do you have any outstanding debts with the City of Hartford for any previous event(s)? |
| □ Yes □ No |
| If yes, list for all City Department owed, date incurred and amount(s). |
| Have you paid the outstanding fees? □ Yes □ No If yes, please submit a copy of receipt. Do you have a payment arrangement with the City of Hartford for previous event(s)? |
| □ Yes □ No |
| If yes, please submit a copy of payment arrangement letter. |
Does the event(s) require the direct involvement by City of Hartford personnel, equipment or other service support?
□ Yes □ NoIf yes, indicate the type (Police, Fire, and Public Works) and specific dollar amount of services required.
Please provide the proposed concert(s) information below:
| EVENT DESCRIPTION | |
| Title of Event/Performer(s): | |
| Date/Time: | Rain Date: |
| Location: | Rain Location: |
| Anticipated Audience: | Handicapped Accessible? |
| Brief Description of Event and Music Presented: | |
| EVENT DESCRIPTION | |
| Title of Event/Performer(s): | |
| Date/Time: | Rain Date: |
| Location: | Rain Location: |
| Anticipated Audience: | Handicapped Accessible? |
| Brief Description of Event and Music Presented: | |
| EVENT DESCRIPTION | |
| Title of Event/Performer(s): | |
| Date/Time: | Rain Date: |
| Location: | Rain Location: |
| Anticipated Audience: | Handicapped Accessible? |
| Brief Description of Event and Music Presented: | |
| EVENT DESCRIPTION | |
| Title of Event/Performer(s): | |
| Date/Time: | Rain Date: |
| Location: | Rain Location: |
| Anticipated Audience: | Handicapped Accessible? |
| Brief Description of
Event and Music Presented:
|
|
Financial Information
(List other funding, applied for, if applicable and the total amount you are requesting form the Preston Fund.)
| Proposed Income Budget |
Amount |
Committed (pending, verbal or written) |
|
Applicant Cash |
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Business Support |
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Foundation Support |
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Government Support |
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Concessions |
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Other (Please define) |
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Request from Preston Fund |
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| TOTAL INCOME |
Indicate the type of expenses that you plan to cover with this grant. Please see the guidelines for eligible expenses.
| Proposed Expense Budget |
Amount |
Notes |
|
Salary Expense |
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Artist Fees |
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Production Expense |
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Sound |
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Lighting |
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Staging |
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Rental (detail) |
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Marketing Expense |
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Printing (i.e., flyers) |
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Insurance |
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|
City Services |
□ includes 50%
Council waiver □ does not include 50% Council waiver |
|
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Other (Please define) |
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| TOTAL EXPENSES |
Income Budget Detail
| List sources individually | Most recent amount received | Year received |
| Foundation Support | ||
| Government Support | ||
In-Kind Contribution
Describe any volunteer work or contributed goods/services for each event. Include the source and estimated value. This list may include business, civic or corporate sponsorship.
|
Source |
Goods/Services |
Estimated Value |
| TOTAL IN KIND VALUE |
If you are not fully funded by the Preston Fund, what is the contingency plan? You must complete this section.
| Declaration: | ||
|
·1 I have carefully read the eligibility criteria for this program, which are described in the application guidelines, and I meet the criteria.·2 I have already submitted the final report for the previous Evelyn W. Preston Fund Grant. I understand that my application will be considered ineligible if my final report is outstanding.·3 I accept the conditions of this program.·4 I certify that the statements in my application are true and complete, to the best of my knowledge.
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| AN ORIGINAL SIGNATURE IS REQUIRED. | ||
| Applicant: Organization or Individual | ||
| Print Name:
Signature: |
Title: |
Date: |
| Fiscal Agent, if applicable: | ||
| Print Name: | ||
| Signature: | Title: | Date: |
| PLEASE MAIL ALL APPLICATIONS TO: |
| Andres Chapparo, Jr. |
| Cultural Affairs Office |
| Department of Health and Human Services |
| City of Hartford |
| 2 Holcomb Street |
| Hartford, CT 06112 |