(Note: Applicant to fill blank boxes, USADF Staff will update shaded areas (NA) after the site

visit).

Country: Name of
Project:
Estimate of Local Currency: NA Investment Type:
Funding Request: U.S. $ equivalent: NA NA
Length of Project NA Exchange Rate: NA
(months)
Legal Name of Applicant:
Other Names Applicant is known
by or does business as:
Legal Status Type of Applicant:
*For Enterprise: # of Full Time Male NA Female NA Total NA
Employees
*For Enterprise: # of Part Time NA NA NA
Employees
*For Enterprise: # of Farmers or Male NA Female NA Total NA
Enterprises Supplying Raw
Materials
Applicant Contact Points:
Name of Primary
Contact:
Position:
Telephone:
E-Mail:
Location of the Organization/Business:
Physical Address:
Mailing Address:
City or town [if urban]:
Village [if rural]:
Nearest Town [if rural]:
Event: App. Grant Date
Rcvd.
Date NA NA
SIGN-OFF
I understand that a material misstatement or the omission of material facts may stop the United States African Development Foundation
from providing funding, may require the termination of any funding that is awarded, and may give cause for legal action by the Foundation.
I confirm that I have necessary authority to act for and on behalf of the company in making the foregoing statements and that they are
correct, to the best of my knowledge and belief, and that no statements of fact are omitted from this questionnaire which are necessary in
order to make the statements herein not misleading.
Applicant

* Members OR non-members selling raw materials to the applicant enterprise / cooperative within the past two years
• Members OR non-members to receive trainings from the applicant enterprise / cooperative
• Members OR non-members gaining access to revolving loan or input funds planned in the proposed project
• Full time or part time employees funded through activities related to the proposed project
*Please be sure NOT to double count beneficiaries who will receive multiple benefits from the proposed project.

2018 Call for Application Form Page 1 November 6, 2017

 USADF GRANT APPLICATION
NOTE TO APPLICANT: The Project Funding Application includes four sections below:

A. Organization Information
B. Current Financial Situation
C. Project Proposal Information
D. Project Budget
E. Supporting Documents

Please follow this outline in developing your application request. The answers to the questions below should
be brief and to the point not exceed 10 pages. If your application is accepted, additional details will be
required.

APPLYING FOR AN USADF GRANT IS FREE, THERE IS NO FEE ASSOCIATED

WITH A GRANT APPLICATION.

A. ORGANIZATION INFORMATION

1) The organization was established in ________ (year)

Date of Legal Registration (Month / Day / Year) __mm__ /_day__ / _Year_

2) Please state the mission or purpose of your organization or enterprise. Limit response to one paragraph.

3) Provide a short description of the most significant achievements your organization has made in the past
three years. Limit response to 1 page or less.

Year Achievement
2017
2016
2015

4) Provide a short description of how the organization or enterprise generates its revenues. Limit response to
one paragraph.

5) What is the primary commodity or product that the organization or enterprise produces for revenues? .
Limit response to one paragraph.

Application Revised November 6, 2017

Page 2 of 8
 USADF GRANT APPLICATION

6) If applicable, describe the Ownership Structure:

List of Owners or Founders

Name Citizenship % Ownership

7) If applicable, describe the Governing Structure:

List of Board Members or Executive Committee

Name Citizenship Title

8) If applicable, describe the Management Structure:

List of top five Managers and Senior Staff

Name Qualifications Years with Organization

9) The Organization is made up of _________ active, paid up members (______ male ______ female). What
are the requirements are needed for membership?

Application Revised November 6, 2017

Page 3 of 8
 USADF GRANT APPLICATION

B. CURRENT FINANCIAL SITUATION

1) List any loans (amounts, term, provider), and other liabilities attached to the organization?

Loan Type Value Balance Due

Other:

2) A) List all sources, amounts, and dates of any donor, government or other outside funding received.

Donor Name Date Type (Loan / Grant) Value

Have you requested any other funding (grants or loans) support from other donors, NGOs, government,
private companies, or banks that are still being considered? If yes, please list details below.

Donor Name Date Type (Loan / Grant) Value

B) After the USADF grant has ended, where do you expect to get other sources of funding? If not, why
not? Limit response to one paragraph.

List the name (s) of credible* potential follow on financing organizations you have identified. (*Credible
potential follow on financing means: The group has contacted the source of follow on financing and
understands the requirements to obtain financing from this source.)

Financer Name Type (Loan / Grant) Value

3) Does the organization or enterprise have a trained accountant or bookkeeper? Yes / No

What are their qualifications?

4) Does the organization or enterprise have 2 years of financial statements? Yes / No

Are the statements audited? Yes / No

Application Revised November 6, 2017

Page 4 of 8
 USADF GRANT APPLICATION

C. PROJECT PROPOSAL INFORMATION

1) What is the market opportunity the organization or enterprise is trying to capture? Limit response to one
paragraph. Provide the names of the buyers associated with the market opportunity.

2) How will this grant allow your organization or enterprise to increase its sales revenues and improve farmer
incomes? (50 words or less).

3) List three primary activities that must be completed to increase revenues and improve farmer incomes?

4) What is the biggest risk facing your organization or enterprise and the success of this project? Limit
response to one paragraph

5) If this project is successful …

How many farmers will have improved incomes? .

How will Sales Revenues increase over the next four years?

Baseline Annual Sales Year 1 Year 2 Year 3 Year 4

Revenues

How will farmer incomes increase over the next four years?

Baseline Farmer Year 1 Year 2 Year 3 Year 4

Incomes

Here is an example:
If the organization purchased 100 tons of maize from the farmers in the baseline year, how much maize is the
organization expected to purchase from farmers in years 1, 2, 3 and 4. Multiply the tons times the price of
maize to determine the year to year increase. See the one page guide at www.usadf.gov/apply for additional
assistance in estimating future revenues and incomes.

Application Revised November 6, 2017

Page 5 of 8
 USADF GRANT APPLICATION

D. GRANT BUDGET

1) Estimate the project budget needed for the project to be successful. Please fill in the budget template below.
(Attach a proposed budget).

2) What will the organization contribute to the project (e.g. money, land, labor, existing infrastructure, etc)

Amount requested from USADF: ______________ (in local currency)

*Organization contribution: _______________ (in local currency)

*Contribution from the proposing organization. May be in cash donations or in kind, including, but not
limited to, supplies, infrastructure, volunteer labor, office, storage and meeting space, and organization
operating costs not covered by the grant.

How many hectares of land will be under cultivation for this project?

Will the organization contribute land to the project for infrastructure or other activities? If yes, how many
hectares.

3) Will any other groups be involved in providing technical support for this project? If so, list the
organization and the nature of the support.

Application Revised November 6, 2017

Page 6 of 8
 USADF GRANT APPLICATION

E. SUPPORT DOCUMENTS

1) Provide a copy of your Organization or Enterprise registration document. (Required)

2) If available provide copies of the past two years of financial statements.

3) If available provide a copy of your most recent business plan.

4) Provide three references contacts. (Required)

Please list the three references outside your organization:

Name Relationship Telephone E-mail

Application Revised November 6, 2017

Page 7 of 8
 USADF GRANT APPLICATION

Name of Project
Costs
Category Description in Local Currency
A INFRASTRUCTURE
A.1
A.2

Sub-Total

B EQUIPMENT PURCHASES
B.1
B.2

Sub-Total

C WORKING CAPITAL / INPUTS

C.1 used for:
C.2 used for:

Sub-Total

D TRAINING
D.1
D.2

Sub-Total

E TECHNICAL ASSISTANCE
E.1
E.2

Sub-Total

F ADMINISTRATIVE SUPPORT
F.1
F.2

Sub-Total

Grand Total

Application Revised November 6, 2017

Page 8 of 8