The AKC humAne Fund, InC. GrAnT ApplICATIon

For Women’s Shelters that Permit Pets & Associated Shelters

Qualifications & Eligibility • Applicant must be (A) a not-for-profit organization that provides temporary or permanent housing for victims

of domestic abuse and their pets, or (B), a not-for-profit organization that provides temporary or permanent housing for pets of victims of domestic abuse and has a formal, established working relationship with at least one not-for-profit shelter for victims of domestic abuse. Applicants in category (A) are preferred.

• AKC Humane Fund Women’s Shelter Grants are awarded for essential operational support relating to the housing of pets or capital improvements specifically for the housing and maintenance of pets.

• AKC Humane Fund Rescue Grants may not be used for fundraising purposes.

• An applicant may not apply for an AKC Humane Fund Grant if it has been awarded a grant from the AKC Humane Fund twice in the five calendar year period immediately preceding the application deadline.

• Applicants that are awarded grants must comply with a reporting process as indicated by the AKC Humane Fund.

Application Instructions

• Completed Grant Application form with additional sheets attached as needed. The original form is required and must be signed and dated.

• Financial information regarding your shelter, including most recent financial statements (preferably audited), total current budget for the last completed fiscal year and for the current fiscal year of the organization, and a list detailing the principal sources of ongoing annual support for the organization.

• Copy of the IRS Determination letter confirming 501(c)(3) status.

• A list of three (3) professional references (such as accountant, veterinarian, animal shelter operator, elected official, social worker, etc). Provide name, address and phone number for each reference contact.

• Applicants representing a pet shelter (See category B above) must provide a letter of referral from at least one Shelter for Victims of Domestic Abuse that the applicant assists. The letter must be on the Domestic Abuse Shelter’s letterhead, signed by the Executive Director of the Domestic Abuse Shelter and detail the extent of the relationship between your organizations.

• Applicants representing a pet shelter must complete Attachment A.

ALL applications must include the following materials, in this order:

Applications are accepted on a quarterly basis and must be postmarked by the following dates:February 15, May 15, August 15, November 15

Mail completed applications to:The AKC Humane Fund, Inc.

Attention: Grant Review Committee260 Madison AvenueNew York, NY 10016

260 Madison Avenue New York, NY 10016 Tel 212 696-8200 Fax 212 696-8299 www.akchumanefund.org • Instructions •

Applicant Information

260 Madison Avenue New York, NY 10016 Tel 212 696-8200 Fax 212 696-8299 www.akchumanefund.org • Page 1 of 7 •

Full Legal Name of Applicant

Legal Structure (e.g. corporation, LLC)

Mailing Street Address

City State/Prov Country Postal Code

Phone (nnn) nnn-nnnn

Employee Identification Number (EIN)

Contact Name Contact Title

Email

Website Geographic area served

Year Founded Number of Employees Number of VolunteersMost recent fiscal year end of organizationMM/YYYY

If yes, what year did you submit an application?

4. (a) What is your organization’s purpose statement in its Articles of Incorporation or similar governing document? (b) What is the overall goal and mission of your organization?

5. List the award amount(s), source(s) and purpose(s) of any grants your organization has received from any grantmaking body in the last three years.

2. Have you applied for a grant from the AKC Humane Fund previously? Yes No

YearYYYY

3. Were you awarded a grant from the AKC Humane Fund? Yes NoIf yes, what year were you awarded the grant?

YearYYYY

1. Is your organization (A) A Shelter for Victims of Domestic Abuse or (B) An Animal Shelter only? (Animal Shelters must complete Attachment A)

The AKC humAne Fund, InC. GrAnT ApplICATIon

For Women’s Shelters that Permit Pets & Associated Sheltersv2.2

Applicant Information, continued

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6. In what way or ways has the ability to house pets at your shelter affected residents and your overall mission? (Applicants in Category A (Women’s Shelters) only.)

7. How many and what types of pets do you currently house at your shelter now? (All applicants)

8. How many and what types of pets can you accommodate at your shelter overall? (All applicants)

9. Do you charge residents a fee for housing their pets?(All applicants) Yes No

How LongIf yes, what is the fee per pet? for

Amount

Applicant Information — for Women’s Shelters Only

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10. How do you house pets in your shelter?in a separate room inside the shelter

In residents’ rooms

in a separate building or structure on the shelter’s premises

other (please explain)

11. Do you help residents identify and transition to pet-friendly permanent housing? Yes No

12. Do you have a relationship with a local AKC rescue group or animal shelter? If Yes, please describe and indicate the name and address of the organization.

Yes No

13. Do you currently conduct fundraising activities specifically relating to the housing of pets at your shelter? If Yes, please explain.

Yes No

14. How do you educate staff and residents about the purpose of housing pets at your shelter and caring for pets at your shelter? Include any examples of written procedures if applicable.

15. What percent of pet care at your shelter is carried out by residents, staff, volunteers and others? The total must add to 100%.

Residents

Staff

Volunteers

Others, please specify:

Total – Must be 100%

Grant Purpose – for All Applicants

260 Madison Avenue New York, NY 10016 Tel 212 696-8200 Fax 212 696-8299 www.akchumanefund.org • Page 4 of 7 •

17. Type of grant request (check one) Pet-related operating costs or pet-related capital support

Pet-related special project

A. Anticipated project or program period will start and end .MM/DD/YYYY MM/DD/YYYY

B. Total project budget including both anticipated sources of income and projected expenditures.

C. Other funding sources and amounts received or expected for this project.

18. How will the funds be used, specifically? Provide a detailed proposed use of grant funds (if awarded). Include the following information, if applicable.

16. Amount of funds requested (up to $1,000 per year for a maximum of 3 years. Maximum: $3,000)

$ for each of 1 year 2 years 3 years (check one)

Please indicate the Calendar or Fiscal Year(s) for which you will use this grant:20 20 20

$Total grant request:

Grant Purpose – for All Applicants

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19. What are the outcomes you want to achieve with this grant?

20. What is your plan for accomplishing the outcomes and what is your project timetable?

21. What is the capacity of your organization to carry out the plan?

23. Why should the AKC Humane Fund, Inc. support this project/your organization?

22. How will you evaluate the success and effectiveness of the program?

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Additional Information

Is the organization party to any claim or lawsuit? Yes NoIf yes, please explain.

Are there any business or judgment liens against the organization? Yes NoIf yes, please explain.

Does the organization have any debts outstanding? Yes NoIf yes, please explain.

Is the organization an endorser or guarantor for any debts not listed on this Grant Application or the attached financial statements? Yes No

Application Execution

By signing below, I: (1) represent that I am duly authorized to execute and deliver this Grant Application on behalf of the organization; (2) certify to the truth of my statements above; and (3) authorize the AKC Humane Fund to obtain business credit, legal, criminal reports and other public record of information on the organization in connection with and/or relating to the statements made on this Grant Application. I, on behalf of the organization, further authorize the AKC Humane Fund to verify with others all information contained in this Grant Application.

Date Signed

Printed Name

Name of Organization

Title

Signature

260 Madison Avenue New York, NY 10016 Tel 212 696-8200 Fax 212 696-8299 www.akchumanefund.org • Page 7 of 7 •

Attachment A: For Animal Shelters Please specify how your organization has helped the Women’s Shelter that is recommending you for this grant, and for how long. Indicate by year the number and type of pets your organization has fostered on behalf of victims of domestic violence.