Submitting this form is Phase 1 of a two-phase process to apply for grant funding from Kaiser Permanente San 2015 Grant RFP LOI Instructions for a full description of the Francisco’s Community Benefit Program. Please see the – grant application process, available at our website: The following must be submitted to comply with the Letter of Intent (LOI) process: A one-page letter requesting funding, describing the program that is being applied for and the amount requested, on the and signed by the Executive Director. organization’s letterhead organization’s This completed LOI form, which can be expanded to four pages maximum. The request letter and LOI form must be submitted via email to by Friday, October 30, 2015, 5:00 pm PST in order to be considered eligible for review. Date: Organization & Program Information Organization Name: Executive Director: Email: This Organization is: 501(c)3 charity government agency using a fiscal agent name: – Program Contact & Title: Program Contact Info: Phone: Email: Grant Categories Indicate only one category for which you are seeking funding: 1. Access to Care Chronic Disease Management – 2. Healthy Eating Plant-Based Nutrition – 3. Active Living Increase Physical Activity and Fitness – 4. Safe & Healthy Environments -- Prevent Intentional Injuries Information about Funding and Kaiser Permanente Support Organization, Program and Proposed Grant Expenses, Unduplicated Clients (UDC), Cost per UDC – Organization Program This Requested Grant Total annual expenses Annual # of UDC $ Cost per UDC (leave blank) $ List current/prior funding received from Kaiser Permanente in last 5 years (add more lines if needed). Date Amount Project Title KP contact person or area If you have a Kaiser Permanente employee or physician on your Board, list name and title: List your top 5 funding sources by amount and percentage of the total budget: organization’s Source and type of funding Amount Percentage % % %
Submitting this form is Phase 1 of a two-phase process to apply for grant funding from Kaiser Permanente San Francisco’s Community Benefit Program. Please see the 2015 Grant RFP – LOI Instructions for a full description of the grant application process, available at our website: The following must be submitted to comply with the Letter of Intent (LOI) process: A one-page letter requesting funding, describing the program that is being applied for and the amount requested, on the organization’s letterhead and signed by the organization’s Executive Director. This completed LOI form, which can be expanded to four pages maximum. The request letter and LOI form must be submitted via email to by Friday, October 30, 2015, 5:00 pm PST in order to be considered eligible for review. Date: Organization & Program Information Organization Name: Executive Director: Email: This Organization is: 501(c)3 charity government agency using a fiscal agent – name: Program Contact & Title: Program Contact Info: Phone: Email: Grant Categories Indicate only one category for which you are seeking funding: 1. Access to Care – Chronic Disease Management 2. Healthy Eating – Plant-Based Nutrition 3. Active Living – Increase Physical Activity and Fitness 4. Safe & Healthy Environments -- Prevent Intentional Injuries Information about Funding and Kaiser Permanente Support Organization, Program and Proposed Grant – Expenses, Unduplicated Clients (UDC), Cost per UDC Organization Program This Requested Grant Total annual expenses Annual # of UDC Cost per UDC (leave blank) $ $ List current/prior funding received from Kaiser Permanente in last 5 years (add more lines if needed). Date Amount Project Title KP contact person or area If you have a Kaiser Permanente employee or physician on your Board, list name and title: List your organization’s top 5 funding sources by amount and percentage of the total budget: Source and type of funding Amount Percentage % % %