Form Application Form 1 Application Form 1 Program Information Sheet

PROGRAM INFORMATION SHEET
1. Applicant Information
a. Legal Name (5a from SF424S):
b. Applicant D-U-N-S® Number (5f from SF424S):
c. Does your organization have a current Central Contractor Registration (CCR)?
Yes
No
If yes, what is the expiration date of your registration?
d. Organizational Unit (if different from Legal Name):
e. Organizational Unit Address
Street1:
Street2:
City:
County:
State:
ZIP+4/Postal Code:
f. Organizational Governance (Check one):
State Government
Public/ Indian Housing Authority
County Government
Nonprofit with 501C3 IRS Status (Other than
City or Township Government
Institution of Higher Education)
Special District Government
Nonprofit without 501C3 IRS Status (Other than
Regional Organization
Institution of Higher Education)
U.S. Territory or Possession
Private Institution of Higher Education
Independent School District
Individual
Public/ State Controlled Institution of Higher
For-Profit Organization (Other than Small Business)
Education
Small Business
Indian/ Native American Tribal Government
Hispanic-serving Institution
(Federally Recognized)
Historically Black College or University (HBCU)
Indian/ Native American Tribal Government (Other
Tribally Controlled College or University (TCCU)
than Federally Recognized)
Alaska Native or Native Hawaiian Serving Institution
Indian/ Native American Tribally Designated
Non-domestic (non-US) Entity
Organization
Other (specify)
g. Organizational Unit Type (Check one):
Academic Library
Library Association
School Library or School District
Aquarium
Library Consortium
applying on behalf of a School
Arboretum/Botanical Garden
Museum Library
Library or Libraries
Art Museum
Museum Services Organization/
Science/Technology Museum
Children’s/Youth Museum
Association
Special Library
Community College
Native American Tribe/Native
Specialized Museum **
Four-year College
Hawaiian Organization
State Library
General Museum*
Natural History/Anthropology
State Museum Agency
Graduate School of Library and
Museum
State Museum Library
Information Science
Nature Center
Zoo
Historic House/Site
Planetarium
Institution of higher education
Historically Black College or
Public Library
other than listed above
University (HBCU)
Research Library/Archives
Other, please specify:
History Museum
*A museum with collections representing two or more disciplines equally (e.g., art and history)
**A museum with collections limited to one narrowly defined discipline (e.g., textiles, maritime, ethnic group)

2. Organizational Financial Information
a. Please complete the following table for the applicant Organizational Unit for the three most recently completed fiscal years.
Fiscal Year
Total Revenue*
Total Expenses**
Surplus or Deficit
FY
FY
FY
* For nonprofit tax filers, Total Revenue can be found on Line 12 of the IRS Form 990.
** For nonprofit tax filers, Total Expenses can be found on Line 18 of the IRS Form 990.
b. If you had a budget surplus or deficit above or below 10% of your annual operating budget for any of the three most recently
completed fiscal years, please explain the circumstances of this surplus or deficit in your application narrative.

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c. Were there any material weaknesses identified in your prior year’s audit report?
Yes
No
Not applicable
A material weakness is a deficiency, or combination of deficiencies, in internal control, such that there is a reasonable possibility that
a material misstatement of the entity’s financial statements will not be prevented, or detected and corrected on a timely basis.
If yes, please explain below.
d. Has your organization had an A-133 audit in the past three years?

Yes

No

3. Grant Program Information
st

a. Laura Bush 21 Century Librarian Program
Select One Funding Category:
Project Grant
Collaborative Planning Grant
National Forum Planning Grant
Select One Project Category:
Master’s-level Programs
Doctoral-level Programs
Early Career Development
Continuing Education
Programs to Build Institutional Capacity

d. Museums for America
Select One Project Category:
Learning Experiences
Community Anchors
Collections Stewardship
e. National Leadership Grants—Museums
Select One Project Category:
Learning Experiences
Community Anchors
Collections Stewardship

b. National Leadership Grants—Libraries
Select One Funding Category:
Project Grant
Collaborative Planning Grant
National Forum Planning Grant
Select One Project Category:
Advancing Digital Resources
Demonstration
Research

f. Museum Grants for African American History
and Culture
g. Native American/Native Hawaiian Museum Services

h. Sparks! Ignition Grants
Select Museum or Library:
Museum
Library

c. Native American/Native Hawaiian Library Services
Select One Funding Category:
Basic Grant Only
Basic Grant with Education/Assessment Option
Enhancement Grant
Native Hawaiian Library Services

4. Please check this box if your project addresses the Campaign for Grade Level Reading initiative:
5. Funding Request Information
a. IMLS funds requested:

b. Cost share amount:

6. Project Subject Area
Please select the subject area(s) addressed by the proposed project:
21st Century Skills
Afterschool/Out-of-School
Broadband
Civic/Community Engagement
Collections Care/Preservation
Cultural Heritage/Sustainability
Early Learning
Economic/Community Development
Education Support
Environment and Energy

Global Awareness
Health
Information Infrastructure/Systems/Workflows
Learning Tools and Interactives (Information/Media
Literacy)
Lifelong Learning/ Intergenerational
STEM (Science, Technology, Engineering, Math)
Workforce Development/Job Assistance
Other (specify):

7. Population Served
Please select the population(s) served by the proposed project:
General Population
Early Childhood/Preschool (0-5 years)
Middle Childhood/Primary School (6-12 years)
Adolescents/High School (13-19 years)
Adults
Aging, Elderly, Senior Citizens (65+ years)
Ethnic or Racial Minority Populations

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Military Families
People with Mental or Physical Challenges/Disabilities
People who are Low Income/Economically
Disadvantaged
Rural Populations
Unemployed
Other (specify):

8. Museum Profile (Museum Applicants Only)

a.

Is the institution either a unit of state or local government or a private not-for-profit organization that has
tax-exempt status under the Internal Revenue Code and that is organized on a permanent basis for
essentially educational or aesthetic purposes?

b.

Does the institution own or use tangible objects, whether animate or inanimate?

c.

Does the institution care for tangible objects whether animate or inanimate?

d.

Are these objects exhibited by the institution to the general public on a regular basis through facilities
the institution owns or operates?

e.

Is the institution open and exhibiting tangible objects to the general public at least 120 days a year
through facilities the institution owns or operates?

f.

Institution’s attendance for the 12-month period prior to the application

g.

Year the institution was first open and exhibiting to the public

h.

Total number of days the institution was open to the public for the 12-month period prior to application

i.

Does the institution employ at least one professional staff member, or the fulltime equivalent, whether
paid or unpaid, who is primarily engaged in the acquisition, care, or exhibition to the public of tangible
objects owned or used by the institution?

j.

Number of full-time paid institution staff

k.

Number of full-time unpaid institution staff

l.

Number of part-time paid institution staff

Yes

No

Onsite

Offsite

Yes

No

m. Number of part-time unpaid institution staff

9. Project Elements (Museums for America and National Leadership Grants-Museums Applicants Only)
Your response to this question will help us match your application to reviewers with appropriate experience. Begin by choosing the
project category that you selected in Question 3 (Grant Program Information).
LEARNING EXPERIENCES
If you are applying in the Learning Experiences Project Category, select the primary element that is
core to your proposed project from the list below.
Exhibitions
Education Programs
Interpretation
Professional Development/Training
Public Programs
Publications
Research
Technology: Public Interface (websites, social media, apps)
Other:

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COMMUNITY ANCHORS
If you are applying in the Community Anchors Project Category, select the primary element that is core
to your proposed project from the list below.
Audience Development/Visitor Services
Evaluation/Visitor Studies
Organizational Planning and Development
Professional Development/Training
Research
Technology: Infrastructure Improvement (software, hardware)
Other:
COLLECTIONS STEWARDSHIP
If you are applying in the Collections Stewardship Project Category, select the primary element that is
core to your proposed project from the list below.
Collections Management
Conservation
Survey
Treatment
Environmental Improvement
Professional Development/Training
Rehousing
Research
Technology: Collections Related (scanning, digitization, database management)
Other:
Types of Material
For conservation projects only. Please identify the material type(s) that will be primarily affected by
your project.
Animals, living
Animals, preserved
Architecture
Books and Paper
Electronic Media
Objects
Paintings
Photographic Materials
Plants, living
Plants, preserved
Textiles
Wooden Artifacts

PLEASE NOTE: Information contained within this form may be made publicly available.

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