13 CAR pt. 50, Appendix A. Forms

` Forms ` CURTIS H. SYKES MEMORIAL GRANT PROGRAM APPLICATION 1. Title of Project. 2. Sykes grant request. $ 3. Total project cost. $ 4. Name, address, and telephone number of applicant organization. 5. Project director’s name and mailing address (if different from above) (Name) (Address) (City) (State) (Zip) (Email/alternate telephone) 6. Telephone 7. Title/position 8. Fiscal agent’s name and mailing address (if different from above). (Name) (Address) (City) (State) (Zip) (Email/alternate telephone) 9. Telephone 10. Title/position Continued on the next page ` 11. Proposed grant period (The period during which grant funds will be spent). From: To: Month Day Year Month Day Year 12. Program date(s) (when project events will take place? 13. Communities in which programs will take place? 14. Project description. Continued on the next page ` I/we certify that all requirements of the organization submitting this application have been met in the preparation of this application, and that all applicable State of Arkansas laws and regulations will be complied with in the completion of this project. Name of Authorizing Official (Please print name) Fiscal Agent (please print name) Signature of Authorizing Official Fiscal Agent Signature Date Date Continued on the next page 15. Will this project result in material to be archived at the Arkansas History Commission? If so, please elaborate. ` Curtis H. Sykes Memorial Grant Program Application BUDGET SUMMARY FORM Item Cost-Share 4. BHCA Grant Cash From Applicant In-Kind Cash From Other Sources Requested 5. Total 1. Personnel a. Salaries and wages b. Fringe benefits c. Honoraria 2. Travel 3. Supplies and materials 4. Printing and duplicating 5. Postage and telephone 6.Equipment rental or purchase 7. Facilities rental (including lodging in 2) 8. Advertising 9. Other (specify) TOTALS IMPORTANT: Please attach an explanation of each budget item. The Budget Justification should contain enough information to show that the costs are reasonable and directly related to the plan of activities for the project. Please organize the budget explanation in the same way that the expense summary is organized. Mail or deliver 10 copies of completed application to the Arkansas History Commission, One Capitol Mall, Room 2B-215, Little Rock, AR 72201. Call the AHC at 501-682-6900 if you have questions or need assistance. ` Curtis H. Sykes Memorial Grant Program GRANT PROGRESS REPORT Each grant contract indicates a due date for submission of a progress report. Please complete and return this form to the address listed at the end of this form by the date listed in your grant contract. Release of remaining grant funds is contingent on submission of this form and subsequent review and approval by the Black History Commission of Arkansas. Grant Period: To (m/d/y) From (m/d/y) Period covered by this report: To (m/d/y) From (m/d/y) Grant Number: Project Title: Grantee: Address: PO or Street Address City State Zip Please provide a brief description of the project’s progress to date: ` Continued on the next page I/we certify that is project is being carried out in accordance with the application approved by the Black History Commission of Arkansas: Project Director Signature Date Mail completed progress report to the Arkansas History Commission, One Capitol Mall, Room 2B-215, Little Rock, AR 72201. Call the AHC at 501-682-6900 if you have questions or need assistance. Do you anticipate being able to complete the project on time: Yes No If no, please explain why: ` Curtis H. Sykes Memorial Grant Program FINAL REPORT Each grant contract indicates a due date for submission of a final report. Please complete and return this form to the address listed at the end of this form by the date listed in your grant contract. Please also include with your submission of the final report: • Copies of project material to be donated to the Arkansas History Commission • Release form, if required, for any project materials to be donated to the Arkansas History Commission • Two copies of any promotional material developed for the project (i.e., posters, flyers, brochures) • Copies of all publicity or coverage that appeared in any publication such as a newspaper, magazine or newsletter • Good quality photographs of project activities Failure to complete and submit all grant forms will result in grantee not being considered for future grant funding from the Black History Commission of Arkansas. Please type your answers to the questions in the spaces provided: 1. Grant Number: 2. Project Title: 3. Grant Period: To (m/d/y) From (m/d/y) 4. Period covered by this report: To (m/d/y) From (m/d/y) 5. Grantee: 6. Address: PO or Street Address City State Zip Continued on the next page ` Continued on the next page 7. Describe what this project accomplished: 8. Please evaluate the success of your project, how your organization learned or grew from the project, and what you would do differently if given the opportunity? ` Continued on the next page 9. Did this project result in the creation or collection of any historical documentation. If yes, please explain. 10. Will you be returning any grant funds to the Black History Commission of Arkansas? If yes, how much do you anticipate needing to return? ` FINAL FINANCIAL REPORT Item Cost-Share 4. BHCA Grant Cash From Applicant In-Kind Cash From Other Sources Requested 5. Total 1. Personnel a. Salaries and wages b. Fringe benefits c. Honoraria 2. Travel 3. Supplies and materials 4. Printing and duplicating 5. Postage and telephone 6.Equipment rental or purchase 7. Facilities rental (include lodging in 2) 8. Advertising 9. Other (specify) TOTALS I certify that all requirements of the organization submitting this application have been met, and that all applicable State of Arkansas laws and regulations will be complied with in the completion of this project. Project Director Signature Fiscal Agent Signature Date Date AHC Disbursing Officer Signature Date Mail completed final report to the Arkansas History Commission, One Capitol Mall, Room 2B-215, Little Rock, AR 72201. Call the AHC at 501-682-6900 if you have questions or need assistance. ` SAMPLE ORAL HISTORY INTERVIEW RELEASE FORM Project name: Date: Tape number: Interviewer: Name of person(s) interviewed: Address: Telephone number: Date of Birth: By signing the form below, you give your permission for any tapes and/or photographs made during this project to be used by researchers and the public for educational purposes including publications, exhibitions, World Wide Web, and presentations. By giving your permission, you do not give up any copyright or performance rights that you may hold. I agree to the uses of these materials described above, except for any restrictions, noted below. Name (please print): Signature: Date: Researcher’s Signature: Date: Restrictions, if any: