Grant Report Form

Please complete all information and return this form to the East Missouri Foundation no later than 90 days after the end of the organization’s fiscal year end. Quantify grant funds that remain unused for the fiscal year.

Organization Name:*
Address:*
Person responsible for grant administration:*
Title:*
Phone*
Email*
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Described the measurable goals for the project, including benchmarks for success:*
Report the organization’s success in reaching those goals, including data indicating that you met these goals. Additional sheets may be attached if necessary:*
Provide a short narrative of the implementation of this project, including the involvement of other agencies or organizations.*
Provide a summary of the lessons learned from this project, including any unanticipated positive or negative results.*
Is the project for which you received funds complete?*
- Yes
- No
If yes, when was the project completed?
MM slash DD slash YYYY
What portion of the grant funds provided by the Foundation were used for the project?
Provide a description of the outstanding project elements and the cost for those elements?
What portion of the Foundation funds remain to be spent?
Do you expect to spend all of these funds to complete the project?
- Yes
- No
If no, please provide detail on the portion to be returned and the expected date of return of those funds.
Does this project require ongoing funding?
- Yes
- No
If yes, please describe how funds will be raised to fund its continued operation.
I certify this project has not used any portion of these funds for any purpose other than the purpose stated in the application for grant. Further, no portion of these funds has been or will be used to carry on propaganda or otherwise attempt to influence legislation, to influence the outcome of a public election, to carry on a voter registration drive, to make a grant that does not comply with I.R.C. § 4945(d)(3) or (4), or to finance an activity for any purpose other than the charitable purposes stated in I.R.C. § 170(c)(2)(B).
Name*
Date*
MM slash DD slash YYYY
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