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STCCF Application

Siletz Tribal Charitable Contribution Fund

Step 1 of 4

25%

Please read the STCCF Eligibility Requirements before filling out this application.

1st Application

Check here only if organization is applying for 1st time and has never submitted an STCCF application in the past.

Date(Required)

Applicant Organization:(Required)

Contact Name:(Required)

Title:

Daytime Phone:(Required)

Email Address:(Required)

Mailing Address(Required)

City(Required)

State(Required)

Zip(Required)

County(Required)

Check eligibility criteria below:

Evaluation(s) for past STCCF awards are up-to-date?(Required)

Yes

N/A

Evaluations must be current and up-to-date. Applicants with past due evaluations are not eligible for new awards.

Organization is located within 11-county service area?(Required)

Yes

You can find a list of the approved counties on the STCCF Eligibility Requirements page.

Organization is a Native American entity located in US?(Required)

Yes

If claiming Native American Organization status, explain why you are eligible:(Required)

If selected for an STCCF award, check should be made payable to:(Required)

Organization has an open, unexpended STCCF award?(Required)

Yes

N/A

If yes, award #:(Required)

Evaluation deadline:(Required)

Will funds be expended for awarded purpose by deadline?(Required)

Yes

N/A

Past awards must be expended within 12 months of receipt. If applicant will have an unexpended balance, please contact STCCF.

Will evaluation report be submitted by the deadline?(Required)

Yes

N/A

Project Information

How many will benefit from the proposed project?(Required)

Proposed start date of project:(Required)

Cannot occur prior to distribution of awards for quarter making request.

Grant Category(Required)

The Arts

Drug & Alcohol Treatment

Prevention

Cultural Activities

Environmental & Natural Resources Preservation

Housing

Historical Preservation

Gambling Addiction

Public Safety

Health

Education

Other (please describe)

Other, describe:(Required)

Project Summary(Required)

Briefly summarize (in 3-4 sentences) the purpose of your request. Describe the basic project, types of activities, what will be accomplished, where, target participants, and when:

Capacity & Program Sustainability(Required)

For ongoing programs, describe your organization’s capacity to manage and report on grant funds, complete the project activities, and sustain the program beyond the term of any STCCF funding.
For equipment requests, describe the expected lifetime of equipment and ability to provide adequate storage and security.
Include any collaborations/partnerships related to capacity and success of organization.

Goals & Outcomes

Describe 1-3 goals of organization or project demonstrating how the requested STCCF funding will help achieve those goals.
Goals are specific, measurable, achievable and realistic with defined time frame.

Goal(Required)

Strategy(Required)

Outcome(Required)

Goal

Strategy

Outcome

Goal

Strategy

Outcome

Organization Description(Required)

Clearly and concisely describe the mission and structure of your organization. The information may be used for public media releases and announcements of STCCF awards.

Project Description(Required)

In space provided, concisely and clearly describe the proposed project and activities.

Proposed Project Budget

A. Total Applicant Share Matching Funds SECURED

(Include other funder grants, in-kind volunteer hours, donated materials, project budget)

Total Combined

In no other sources or cash, in-kind, or fundraising is being solicited for this project, please explain why.(Required)

Detailed Project Budget

The detailed budget must show the amounts to be expended for each line item of the project budget over the term of any STCCF award for each column of amount requested from STCCF and applicant share for Secured and Proposed matching funds.
Attach cost estimate/quotes from vendor/contractors for equipment, construction, etc.
Totals for rows and columns are auto-calculated from numbers entered.
The TOTALS of two rows at bottom of page must match for application to be accepted.

Budget Item One

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Two

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Three

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Four

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Five

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Six

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Seven

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Eight

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Nine

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Ten

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Eleven

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Twelve

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Thirteen

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Fourteen

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Fifteen

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Add Another Budget Item(Required)

Yes

Budget Item Sixteen

Budget Items(Required)

(Include quantities and cost per item)

Requested from STCCF(Required)

Secured(Required)

Applicant Share

Proposed(Required)

Applicant Share

TOTALS

Totals

Total Requested from STCCF

Total From Above

Total Secured (Applicant Share)

Total From Above

Total Proposed (Applicant Share)

Total From Above

Total Cost

Total From Above

Total Requested from STCCF

Total From Proposed Budget

Total Secured (Applicant Share)

Total From Proposed Budget

Total Proposed (Applicant Share)

Total From Proposed Budget

Total Cost

Total From Proposed Budget

IF THE 2 ROWS OF TOTALS ABOVE DO NOT MATCH - CHECK ALL ENTRIES ON THIS PAGE.

THE 2 ROWS OF TOTALS MUST MATCH FOR APPLICATION TO BE ACCEPTABLE.

Certification:

By signing the application form, the signer certifies:

The information provided is accurate and that any grant funds received will be used according to the stated purpose and any approved awarded purposes only.
The organization will comply with all STCCF regulations and guidelines.
STCCF funds will expend funding only for the purposes as stated in award notice.
The organization will make reasonable efforts to publicly announce receipt of an STCCF award.
The organization will provide the required evaluation report by the deadline.
The organization will return all unexpended funds by the deadline, unless a written request is submitted and approved in advance of the deadline by the STCCF Advisory Board.
The signatory has the authority to commit the organization to these conditions.

Applicant's Signature(Required)

Date(Required)

A copy of this application will be sent to you via the email provided. Please keep this for your records.

Upload Document(s)

Attach cost estimate/quotes from vendor/contractors for equipment, construction, etc.

Drop files here or

Accepted file types: png, jpg, jpeg, doc, docx, pdf, Max. file size: 10 MB, Max. files: 5.

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Contact Siletz

201 SE Swan Ave.

PO Box 549

Siletz, OR 97380

541-444-2532

Monday-Friday

8:00 AM – 4:30 PM

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