Joods Humanitair Fonds / Dutch Jewish Humanitarian Fund

APPLICATION FORM

CATEGORY 2:
REQUEST FOR A GRANT FOR ORGANIZATIONAL CORE FUNDING TO BUILD INSTITUTIONAL CAPACITY,
FINANCIAL SUSTAINABILITY AND LONG-TERM DEVELOPMENT

This application form and all accompanying documents are to be completed in English.
The application form (including the budget of your organization) must be submitted by July 1st 2010. Other necessary documents should be in our office by July 10th 2010.
Please indicate all amounts in Euros and keep this summary brief.
For amounts in Euros please use rounded amounts and do NOT use dots and commas. Example: 10000 (ten thousand).

Attention: Do not fill out this application form before you have completed a budget!

Click here to review the instructions and find a template of the budget.

1. Applicant:

Name of the organization
Address (street)
No.
Postal Code; city or town
PO Box	(Optional)
Postal code PO Box; city or town PO Box	(Optional)
Country
Phone number (incl. country and area code)
Fax number (incl. country and area code)	(Optional)
Email
Website	(Optional)
Managing Director or Chief Professional Officer
Accountant or bookkeeper of the organization
Associated with any governmental agency or public authority?	No Yes, the institution is part of :

2. Contact Person

First Name
Family Name
Male/Female	Male Female
Direct Phone number (incl. country and area code)
Direct Fax number (incl. country and area code)	(Optional)
Email (for confirmation email)

3. Mission and Activities

Please describe briefly your organization and its mission (maximum 100 words) :

Please describe your organization's activities and/or projects over the past three years (maximum 150 words) :

Please describe briefly the activities/projects that your organization intends to carry out
in the coming year (maximum 150 words) :

4. Request of subsidy for core-business and corefunding

Why do you need core funding of the JHF? (maximum 100 words) :

What do you like to achieve?
Be aware that category 2 Grants are not intended to fund general organizational
deficits of the past. (maximum 100 words) :

5. Total budget, requested amount of the JHF, co-funding, own contribution
Only in very rare instances will JHF fund an organization where JHF is the sole funding source.

		Amount in Euro (€)
Total budget of the organization
Payment requested from the Dutch Jewish Humanitarian Fund [maximum is 50000 Euro]
For which period do you request for the core funding from the JHF?
Start
End

Specify the expected income for the coming year in the table below:
		Amount in Euro (€)
Amount requested from the Jewish Humanitarian Fund [maximum is 50000 Euro]
Contribution from your own organization
Third party/parties funding Name(s) of the organization(s):		Amount in Euro (€)
1.
2.
3.
4.
5.
6. Yields of sales
7. Contributions & fees
8. Other income (please specify)
9. Other income (please specify)
10. Other income (please specify)
11. Other income (please specify)
12. Other income (please specify)

Please, give a description of your organization’s target group, and what the size is of the target group (maximum 50 words):

6. Structure of your organization

Please describe the structure of your organization (maximum 200 words)

How many employees do you have (leadership, project management, administrative, volunteers) (maximum 100 words)?

Do you own your own office?

Yes
No

If no, how much is your rent per year?

To whom do you pay your rent?

7. Details of Bank-account

Note that we can only transfer money to a EURO bank-account. Please fill in all requested items:

BIC beneficiary bank (SWIFT)
IBAN or account number of beneficiary
Exact name of beneficiary as known by the bank
Postal code and city of beneficiary
Country of beneficiary
Name of bank of beneficiary

8. Enclosures

Exhibit A:

Please attach the total budget of your organization for the coming year and a specification of the salaries and if necessary the balance sheets you downloaded and completed earlier with this application in the last step presented to you after submitting this page:

Only in case there are no balance sheets included in your financial annual reports, please attach the balance sheets.

Please be aware that the application form, the project budget, salary specification and in case there is no balance sheet included in your financial annual reports, the balance sheet, must be in our office by July 1st 2010.

Exhibit B:

Please be aware of the following:

Please send the following documents by regular mail. When sending the documents, do not forget to note the name of your organization (the same name you use in the application form).

These documents must be in our office by July 10th 2010.

1.	annual financial reports for the past three years, so 2007, 2008 and 2009, (if the original document was written in a language other than English, it must be translated into English) which has to include a balance sheet, a profit & loss account per year and explanatory notes; Even if you have sent the annual financial reports to our office already in the past, please send them again.
2.	a charter or articles of association of your organization;
3.	a listing of your organization in the official public register;
4.	if available :a published annual report, or its equivalent;
5.	If available: an auditor’s report.

If you have applied before and no legal changes have taken place, it is not necessary to send items 2 and 3 again.

Our address:

Dutch Jewish Humanitarian Fund
P.O. Box 11646
2502 AP The Hague, The Netherlands

9. Print

Please review the data.
After submitting the application form and uploading the Word document with the budget you will be able to print the data for your own archive.

10. Sign & Submit

The undersigned affirms that the form has been completed truthfully.
The undersigned is aware of the stipulations in the Disbursement Regulations for the Dutch Jewish Humanitarian Fund.
The undersigned agrees that the Dutch Humanitarian Fund may request information from any co-financing parties of the project and/or third parties, as required for proper evaluation of the application.

Place

I agree