Please complete all the questions. An incomplete request will be returned and risk the possibility of not receiving funding. You must have JavaScript enabled to use this form. Organization Information Organization Name Organization Address Organization Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Point of Contact Information Name Email Cell Phone Office Phone Type of Agency Requesting Funds Is the applicant a non-profit/501c3 organization in good standing with the IRS and the Nebraska State Department? Yes No Please provide the 501c3 EIN Number Are you using a fiscal/agent or fiscal sponsor? Yes No Please name the organization and EIN Are you sub-granting funds to other organizations or groups? Yes No Please indicate in the proposed program budget the organizations that will receive subgrants and amounts. Please provide the mission statement of the organization. Proposal Information Event/Activity Name Date Place Time What is the purpose of the request? Please describe the proposal. What is the amount requested? $ Explain what the Nebraska Commission on Latino-Americans funds will be used for. List additional funding for the event. Breakdown the information to differentiate “secured” and “pending” requests. List the benefits the Nebraska Commission on Latino-Americans will receive if your funding request is granted. Name and logo recognition Tickets or seats to the event Booth or table Booklet ad Other benefits… Enter other benefits… Please upload a budget of the event/activity that includes a break-down of income and expenses. One file only.20 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Goals and Outcomes What are the goals of the event/activity? What do you expect to achieve? How will you measure your results? What are the intended outcomes? DemographicsPlease share the number/percentage of participants according to the following categories: Male Hispanic/Latino Rural Female Black/African American Urban Non-Binary Native American/Indian LGBTQ+ Asian White Other races/ethnicities Please share the communities where participants will come from- cities, municipalities.
