Cover Sheet

You are submitting a cover sheet for the New York City: Care Coordination Fund (Invitation Only) RFP.

* Indicates a required field

Information about Person Completing the Form

Your Name:

Your Title:

Your Email:

Your Telephone:

Check here if you are the primary contact for this proposal cover sheet

Applicant Organization

EIN:

After entering an EIN, any information we have will display in the fields below. Please review for accuracy and update as needed.
Click here to find your EIN on Guidestar by Candid

Organization:

We are using a funds administrator for the proposed project

Legal Name:

Alternative Name:

DBA or other name your organization may be known as

Year Organized or Incorporated:

Address Line 1:

Address Line 2:

City:

State:

ZIP Code:

Telephone:

Website:

Board Chair or Co-Chairs:

Name of Paid Staff Head:

Paid Staff Head Title:

Paid Staff Head Email Address:

Our organization is accessible to people with disabilities

Organization Description:

Annual Operating Budget:

$ .00

Most Recent Completed Fiscal Year’s Total Organizational Expenses. Whole dollar amounts only, no commas please

To complete the chart below, please just give your best estimate based on the information you currently have easily available.

Total # of Staff:

Total # of Board Members:

The specific ethnic composition of your staff and board is required before you’ll be allowed to save your cover sheet and submit your proposal. Please enter that information in the table below:

	Staff(#)
Ethnicity	Professional	Support	Board(#)
Arab:
Asian:
Black/African American:
Latinx:
Native American:
White, Non-Hispanic:
Other:
Totals:

Primary Contact Person for the Proposed Project (if other than Paid Staff Head)

Contact Name:

Contact Title:

Contact Email:

Contact Telephone:

Population Served by Proposed Project

Age Served:

Select if more than half (51%) of people to be served are in that age range

Gender Served:

Select if more than 75% of people to be served are that gender

Ethnicity Served:

Select if more than half (51%) of people to be served are of that ethnicity/race

Check if more than half (51%) of people to be served are Lesbian, Gay, Bisexual, or Transgender

National Taxonomy of Exempt Entities (NTEE) (required - up to 3 codes) Enter NTEE codes for the Applicant Organization seeking the grant (not the Funds Administrator)

Click here to find your NTEE classifications on Guidestar by Candid

NTEE Code 1:

NTEE Code 2:

NTEE Code 3:

Upload PDF Upload PDF

Please submit the required materials listed in the application instructions. Combine all materials into a single PDF file no more than 25 MB in size. See the application instructions for more information.

Certification

I certify that the information provided on this form is true to the best of my knowledge.

You will receive a PDF of this cover sheet once it is submitted.

The New York Community Trust reserves the right to share information provided on this form during the evaluation of the proposal.