AMELIA PEABODY FOUNDATION

GRANT REPORT FORM

COVER SUMMARY:

1. Legal name of organization:_____________________________________________________

2. Name of Fiscal Sponsor (if different from organization):_____________________________

3. Address of Organization:_______________________________________________________

4. Executive Director:____________________________________________________________

Phone: ___________________    Fax: _______________________ Email:___________________

5. Period this report covers:_______/_______/________ to _______/______/________

6. Grant Amount: $ __________________________

7. If a multi-year grant please give amounts by year:

Year One:_____________ Year Two: ______________Year Three: _______________

8. Please indicate whether this is a:

• Final Report (at the end of the grant period): _________, or an

• Interim Report (at the end of each year during a multi-year grant period):
  Year ________

9. Please indicate whether the grant was for (check more than one category if appropriate):

Operations ____________ Program _____________ Capital ______________

(By Operations, we mean the general operations of the organization. By Program, we mean a particular program

within the general operations, which could be either a new program, or an existing program, or the attempt to lift

an existing program up to a new level of performance. By Capital, we mean facility purchase, enlargement, renovation

or repair, as well as the purchase of new equipment.)

10. Was the grant made as a challenge, or was your request made in response to a challenge?            

If you answer yes, please tell us about nature of the challenge and whether the challenge has been met.        

_______________________________________________________________________________

_______________________________________________________________________________

REPORT NARRATIVE AND REPORT ACCOUNTING:

The report should include both a narrative and a line-by-line accounting of how the grant monies were spent.

Below we list the kinds of things that we would like to see in your report. The list is not intended to be

complete. You may want to add other information that seems to you relevant and important. You may want

to change the order. If during the period of the grant, there have been significant changes in your organization,

please advise us. For example, report on changes in your leadership, in your goals and objectives, in the

population served. Most of all, the report should make it clear how the grant monies were spent. The report

should include a line-by-line accounting and the signature of the person responsible for the content. Please

try to limit your report, including cover page, narrative and accounting, to five pages or less.

In the case of a multi-year grant where additional funding is to be released please provide a copy of the most

recent IRS letter confirming tax-exempt status of the applicant or fiscal sponsor, and the interim reports

should warn of any future difficulties that are anticipated, either in spending the allotted money or in regard

to the project itself.

THE REPORT NARRATIVE:

1. Describe what this grant has supported.

2. Describe the impact that the grant has had. For example, did the grant monies improve or enable you

to expand your operations in any significant way?

3. If the grant is part of a larger project please tell us of the progress to date of that larger project.

4. Describe any setbacks or disappointments during the grant period, and how you have dealt with them.

5. If the grant allowed you to make beneficial changes to your operations, how will you be able to
   sustain these changes in the future?

6. If another organization was involved in the project, how did the collaboration work out?

7. Describe how you evaluate the success of the project the grant supported?

8. Was the proposed project budget successfully raised? In addition to Peabody monies what other
   funds were raised for this program or capital project?

9. Tell us if there are unspent grant monies and what you propose to do with them. To redirect them,
   you will need to send us a written proposal to which we will respond.

THE REPORT ACCOUNTING:

1. If the grant was for general operations please provide a general operations accounting for the period
   of the grant and, when possible, provide a tracking of how the Peabody grant monies were used.

2. If the grant was for program be sure you send us a complete program accounting. When possible,
   provide a tracking of how the Peabody grant monies were used. Also, if other monies were used for
   this particular program please tell us the amounts and sources of these monies.

3. Capital grants may be part of a large multi-year capital campaign where fund raising is still going on.
   But capital grants may be for single, well-defined projects such as new equipment purchase and
   facility renovation and repair. Your accounting will vary accordingly. If a multi-year capital campaign,
   please provide start and finish dates, amounts raised to date, and amounts still to be raised. We would
   like to see our grant within the context of the entire capital campaign.

4. In any case, if a grant specific line item accounting is not available please provide a statement, signed
   by a person with fiscal authority, as to the total amount of granted funds expended to date.

Send a hard copy of this report to:

Amelia Peabody Foundation

1 Hollis St.

Wellesley, MA 02482-4677

Additionally, please email this report as an attachment to: jsmith@ameliapeabody.org

Note: Please put your organization's name in the Subject line. Similarly, attached documents should be labeled
with your organization's name rather than the foundation's. Microsoft Word and Excel documents are
preferred. You may be asked to re-submit incompatible formats.

Name of person completing this report: ________________________________________

Signature:__________________________________________ Date: _____/_____/_____

Title: ___________________Phone: ________________ Email: ___________________

REPORTS MUST BE SUBMITTED BY THE YEAR-END DATE (or dates in the case of a multi

-year grant) SPECIFIED IN THE GRANT AGREEMENT.