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Community Grant Evaluation Form

At the completion of the project, Recipients of the Capital Grant or the Program/Event Grant must submit this completed Evaluation Form with supporting documents to the Clerk’s Division. Submissions must be made within two months of the completion of the event or project.

Recipients shall include with the completed Evaluation Form:

A Financial Report including project income and expenditures as well as receipts/invoices for all expenses (Part C).
Financial Statements for the year the project was undertaken (Capital Stream Recipients only)
Proof of recognition in accordance with the Community Grant Recognition Protocol (Part D).
Photos of the completed project, program, or event.

All evaluation forms can be submitted by:

Online
Email: clerk@loyalist.ca
In-person/Mail: 263 Main Street Odessa, ON K0H 2H0 Attn: Clerk's Division

Part A - General Information

Organization Name:

Phone:

Contact Name:

Email:

Address:

Project/Program/Event Name:

Project/Program/Event end date:

Grant amount:

Under which Stream did you receive a grant?

Capital Grant Stream

Program/Event Stream

Part B - Description of the Project/Program/Event

Describe the specific Project/Program/Event outcomes or results achieved:

Was the project/program/event completed as described in your proposal?

Yes

If the project/program/event was not completed as proposed, explain why? If completed, what factors contributed to that?

Please specify the project/program/event location:

Please indicate (estimate) the number of participants:

Volunteers:

Staff, if applicable:

Public participants:

How would you describe the project’s measurable impact on the people or community you serve?

What has been the grant’s measurable impact to date on your organization? For example, has the grant helped to increase participation, increased reach of your organization, or increased volunteer involvement?

As a result of this grant, did your organization increase or enhance partnerships and collaborations with other groups in the community? Explain.

Part C - Financial Report

Financial Statements from Capital Grant Recipients shall be attached.

Income - What was the total amount of grant (including in-kind service) received?

Other Sources of Income:

Income 1

Amount

Income 2

Amount

Income 3

Amount

Income 4

Amount

Income 5

Amount

Income 6

Amount

Income 7

Amount

Income 8

Amount

Income 9

Amount

Total Income (add all total together)

Expenses - Expenses funded by the Grant:

Attach receipts/invoices separately

Expense 1

Amount

Expense 2

Amount

Expense 3

Amount

Expense 4

Amount

Expense 5

Amount

Expense 6

Amount

Expense 7

Amount

Expense 8

Amount

Expense 9

Amount

Total Expenses funded by the Grant:

Expenses funded by other sources:

Attach receipts/invoices separately

Expense 1

Amount

Expense 2

Amount

Expense 3

Amount

Expense 4

Amount

Expense 5

Amount

Expense 6

Amount

Expense 7

Amount

Expense 8

Amount

Expense 9

Amount

Total Expenses funded by other sources:

Part D - Proof of Recognition

Signage Please confirm:

As a recipient of the Program/Event Stream, I am confirm a temporary signage is/was posted acknowledging grant support during the event or program. This signage was posted in a prominent and visible location that took into consideration pedestrian and traffic safety and visibility. OR

As a recipient of the Capital Grant Stream, I am confirming that a permanent signage acknowledging grant support is posted. This signage is placed within/outside a prominent and visible location that takes into consideration pedestrian and traffic safety and visibility.

Please attach pictures of the temporary or permanent signage as proof.

Please select the communication type where you recognized Windlectric Inc, Kingston Solar GP Inc. and Loyalist Township for their support, as per the Community Grants Recognition Protocol:

Print Media:

Social Media:

Special Events:

Media Releases:

Website

Other (please describe):

Part E - Confirmation and Signature

Please Check:

I am attesting that the information provided in this evaluation is true and correct as of the date.

I understand that the information collected through this evaluation form may be used to promote the Loyalist Community Grant Program through various media except where it is subject to exemptions under the Municipal Freedom of Information and Protection of Privacy Act.

I am confirming that I have attached (Receipts/invoices for all expenses, Financial Statements for the year the project was undertaken (Capital Stream Recipients only), Proof of recognition in accordance with the Community Grant Recognition Protocol, Photos of the completed project).

Receipts/invoices for all expenses

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Financial Statements for the year the project was undertaken (Capital Stream Recipients only)

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Proof of recognition in accordance with the Community Grant Recognition Protocol

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Photos of the completed project

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Name:

Date:

Signature:

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