San Francisco Public Health Foundation
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Fiscal Sponsorship Application
Year Organization was founded
Name of Organization
1) Total organization budget: Current year $
Previous year (actual expenses) $
2) Number of full-time paid employees:
Part-time paid employees:
Number of volunteers:
Total number of volunteer hours:
3) Does your organization maintain a bank account in its own name?
If yes, please give the bank name and address
4) Does your organization have an Employer Identification Number (EIN)?
If yes, what is your organization’s EIN:
5) Do you plan to seek 501(c)(3) status from the IRS at some point?
6) Why was this organization founded?
7) Does the organization have a current or previous fiscal sponsor? (If yes, provide name, contact person and phone number and explain reason for seeking new fiscal sponsor.)
8) Describe your current activities and recent accomplishments:
9) What is your work plan for the coming year?
10) Describe the structure of the organization, including a description of how decisions are made? (If you are the founder of a new group, what is your plan to make the group bigger than yourself?)
11) Who benefits from the work of your organization? Describe any underserved communities or groups that benefit from your work. Do your volunteers and staff reflect the diversity of the communities served by your group?
12) Describe community involvement: How does your organization reach out to the public? What groups or individuals will your organization collaborate with?
13) Why does your organization seek fiscal sponsorship from the San Francisco Public Health Foundation?
14) How will the organization raise money?
15) What other (if any) organizations are providing similar programs in this geographic area?
16) Does the organization try to influence elections? (i.e. endorse candidates for office, help with campaigns, hold candidate forums?)
BUDGET AND FINANCIAL INFORMATION
You may fill out this form or attach a spreadsheet. The following worksheet is to help you estimate expenses and income. Feel free to attach your own budget instead of using this worksheet. Please estimate volunteer labor and donated goods and services under "non-cash contributions." The categories below are only suggestions; feel free to use your own categories.
What time period does this budget cover?
Click here to download the Budget Worksheet
Please include the following ATTACHMENTS with the application form
Organizational budget (or use the worksheet above)
Implementation Plan with Timeline for the Project
List of Board of Directors, advisory board or steering committee members with affiliations
List of key staff and/or volunteers with description of responsibilities
Organizational financial statement from most recent completed fiscal year (if applicable)
The following ATTACHMENTS are OPTIONAL:
1. Press clippings
2. Newsletters or other publications
3. Letters of support (maximum of 2)
Please list contact information for two people or groups familiar with your organization that we may contact (please include phone numbers and e-mail addresses and relationship to your organization):
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Our Current Projects
Direct Patient Services
Communicable Disease Control
Outreach and care for special populations
Public health outreach, education, prevention and administration
Youth and children’s prevention and services