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The Mary Free Bed Fund 235 Wealthy Street (Mary Free Bed Rehabilitation Hospital)

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The Mary Free Bed Fund
235 Wealthy Street SE
Grand Rapids, Michigan 49503
Application Information and Questionnaire
Thank you for your interest in the Mary Free Bed Fund. The following information and
Questionnaire will assist you in submitting your request for funding.
Background
Mission Statement: The primary mission of the Mary Free Bed Fund is to support the
charitable, scientific, and educational purposes and missions of the Mary Free Bed Guild and its
subsidiaries. The Mary Free Bed Fund also supports activities and organizations whose focus
is on the education, recreation, health and well being of the disabled population in western
Michigan. In addition, the Fund will support community organizations that promote the mission
and direction of the Mary Free Bed Guild and its subsidiaries.
Consideration is given to requests that fulfill the following:
. Involve people with disabilities
. Demonstrate a direct relationship with the Fund Mission Statement
. Serve those in West Michigan
. Are collaborative, innovative, or have the potential for being on
going.
Evaluation of Requests
Each request receives careful attention. When questions arise, the applicant
may be contacted for further information.
The Fund Board meets the third Tuesday of September, November, January,
March, and May.
Requests must be received by the first business day of the meeting month.
Requests received after that day will be considered at the next scheduled meeting.
You will receive notice of the status of your request within thirty days after your
proposal is considered.
Thank you for your cooperation.
Susan Bloss
Mary Free Bed Fund Board President
Please complete the following questionnaire and return it with a copy of your proposal and
completed application to:
Guild.Administrator@maryfreebed.com
Fund/Internal Request Form
07/21 – Finance
MARY FREE BED FUND
SPECIAL REQUESTS
APPLICATION FORM & QUESTIONNAIRE
Date:
1.
Title of Project: ________________________________________________________________
New Request Renewal
Will this be an annual request? Yes No
If so, what is the approximate request date? ________________
If approved, please indicate when you will need to receive the funds. ________________________
2. Applicant Information:
Organization:__________________________________________________________________
Contact Name: ____________________________________ Contact Phone:_______________
Address:______________________________________________________________________
City:___________________________________ State: __________________ Zip: ___________
Tax Exempt Status: 501(c)(3) Tax ID Number: __________________
3. Amount Requested: $___________________ ___________________
4
.
5.
Describe the project, its goals, and explain how it will improve the lives of people with disabilities.
FUND BOARD ACTION:
Project #
Date Reviewed
Approved Denied
Sackner Funds
Other Funds
Total Approved
Page 1 of 3
6.
Start Date _____________________________ End Date: ________________________
Specific geographical area to be served: ___________________________________________
Target population:
___________________________________________________
Number of people served by project: ____________________________
Ages of people served: _______________________________________
Percentage of population served under the age of 18:_________________________________
Please provide the following information regarding your project:
7.
Budget: Please attach detailed request
Briefly describe your organization and its goals.
Fund/Internal Request Form
07/21 – Finance
Give a concise statement of the purpose of the program and the need it addresses:
Yes No
Is this a new project? Yes No
Are you aware of other organizations offering a similar program?
If so, what are they?
How will the program be implemented? Include a timeline for the work.
How will the program be evaluated and the results measured?
What is y
our pl
an to
secure continued support
f
or this program?
List the names and qualifications of the individuals that will implement the program:
Page 2 of 3
List other sources being asked to support the program:
If we are unable to fund this request, how will the program continue? Are there any plans to find
funding elsewhere?
Fund External Request Form with Guidelines
07/21 Finance
Required documents (for all new and renewal applications):
Current and past year total event budget, or organizational operating budget, with separate
columns for current and past year budgets (explain any line items that show a significant change
between the two years)
An accounting of the most recent year’s activities including:
balance sheet and income statement (audited statements preferred)
donor breakdown (include all major donors and amounts donated last year)
expense breakdown
Any additional information about your programs or financial situation that would help to clarify
items in the request
Tax exempt letter or evidence of your tax-exempt status
Renewal applicants must also provide:
Assigned project # on all correspondence
Annual reports for continuing projects, including documentation on how funds from previous
year were used and when.
One-Time Projects must provide:
Documentation/reports to show that the funds received were spent per the project request
Page 3 of 3
Please return completed questionnaire and all additional documents to:
Guild.Administrator@maryfreebed.com
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The Mary Free Bed Fund 235 Wealthy Street (Mary Free Bed Rehabilitation Hospital)

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Completed 17 July 2021

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