Care Access Grant Application Questions – Superior Health Foundation

Program name:
Amount requested:
Project start date:
Project end date:
Organization’s Mission: Please describe the organization’s mission and current
programs and services.
Target population: Who will benefit from this funding?
Number served: How many people have benefitted from this financial assistance
over the past year? How many were UP residents?
Geographic reach: Which U.P. counties will this funding target?
Needs: Please briefly describe (no more than three paragraphs) the care needs the
organization addresses.
Assistance criteria: What criteria does the organization use to determine the need
for financial assistance? Please include a copy of the organization’s financial
eligibility policy here or as an attachment.
Budget: Please upload a budget detailing how the funds will be spent (if known at
this time).
Attachments: Please include the following attachments
1. IRS determination letter or tax-exempt documentation
2. Organizational chart
3. Board roster
4. Annual operating budget
5. Most recent financial statements, 990, or audit
6. Letters of support (optional)